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HEALTH SERVICES
Bravo Health utilization management staff base their utilization-related decisions on the clinical needs
of its Members, the Member’s Benefit Plan, the appropriateness of care, Medicare National Coverage
Guidelines, objective, scientifically-based clinical criteria and treatment guidelines, in the context of
Provider and/or Member supplied clinical information and other such relevant information.
Bravo Health in no way rewards or offers incentives, either financially or otherwise, practitioners,
utilization reviewers, clinical care managers, physician advisers or other individuals involved in
conducting utilization review, for issuing denials of coverage or service, or inappropriately restricting
care.
If you have any further questions or comments, please feel free to contact our Provider Services
Department at 1-888-353-3789.
Goals
• To ensure that services are authorized at the appropriate level of care and are covered under the
Member’s health plan benefits.
• To monitor utilization practice patterns of Bravo Health’s Contracted Physicians, Contracted
Hospitals, and Contracted ancillary services,
• To provide a system to identify high-risk Members and ensure that appropriate care is accessed.
• To provide utilization management data for use in the process of re-credentialing Providers.
• To educate patients, physicians, contracting hospitals, ancillary services, and specialty Providers
about the company’s goals for providing quality, value enhanced managed health care.
• To improve utilization of Bravo Health’s resources by identifying patterns of over and under
utilization that can be improved upon.
Clinical Review Guidelines
Bravo Health has approved the following guidelines to be used for determining medical necessity and the
appropriateness of care:
• InterQual™ Criteria Guidelines, (ISP, ISX, ISD and SAC)
• Utilization Management Policies and Procedures
• Technology Assessment
• Medicare National Coverage Decision Guidelines
• ASAM for Chemical Dependency and current literature and regulatory requirements for Mental
Health Services (MHN)
• Evidence of Coverage, consistent with the contract definition of Medical Necessity.
Utilization Review decisions approving or denying payment of a service shall be based on the medical
necessity and appropriateness of requested service, the Member’s individual circumstances, and the
appropriate contract language concerning benefits and exclusion.
All criteria utilized are available to any healthcare Provider upon written or verbal request.
