HBI’s Utilization Management (UM) Criteria are developed and approved by the Quality Improvement Committee consisting of highly-experienced clinicians, psychiatrists, psychologists, and plan representatives, and are based on established national standards from:
- American Psychiatric Association
- DSM IV
- HBI clinical experience
- ASAM for Chemical Dependency
- Community standards/cultural sensitivity
When a requested service does not meet the UM criteria, then the case is referred to HBI’s Clinical Director and/or Medical Director for review and a written Notice of Denial is mailed to both the member and provider or facility detailing the reason for the denial and information on the appeal process.
When appealing a denial of service, the provider must contact HBI’s UM Department in writing and provide additional information or documentation to substantiate the reason for more services within a specific time-frame, and request to speak with a peer reviewer.
Based on the new information received, it is HBI’s responsibility to:
- Re-evaluate new clinical information provided;
- Have another peer other than the original reviewer;
- Render a decision to either overturn, or uphold the denial;
- Send the provider and the member a written notice as to the reason for upholding the denial;
- Respond within 45 days (for routine requests); or
- Immediate 72-hour response for urgent requests.
For more information on obtaining prior authorization, contact:
HBI Utilization Management
Fax: (702) 248-9640