Medical Operations Management Decision Making
Medical Operations Management staff at UniCare are responsible for affirming that medical services that are requested for authorization by participating physicians are necessary and appropriate for treating the member's illness or injury, or are needed for disease prevention, in accordance with the member's certificate of coverage. UniCare's benefit decision making is based on appropriateness of care and service. UniCare does not specifically reward its associates for issuing denials and does not offer incentives to encourage inappropriate under or over utilization.
UniCare uses licensed clinical professionals (including RNs, BSNs, and physicians) in its review of medical information. Although technical support staff may assist the clinicians in data gathering, technical staff members are not permitted to make clinical judgments. UniCare's clinical staff relies on published criteria and clinical guidelines for making preliminary benefit assessments of appropriateness. Any case that a nurse is unable to certify based on the criteria is referred to a physician. Treating physicians may contact a UniCare physician reviewer at (312) 234-7178 to discuss benefit denial determinations based on medical appropriateness under the member's certificate of coverage.
UniCare invites practicing physician input into the development of clinical criteria. The UniCare Guidelines and Care Process Subcommittee, composed of participating physicians, is responsible for reviewing, updating, and amending the criteria used by the UniCare Medical Operations Management department. UniCare strongly encourages physicians with concerns about clinical guidelines or criteria to contact the medical director at (312) 234-7178. If you would like your concern reviewed by participating physicians who serve on the Guidelines and Care Process Subcommittee, please submit your written concern to:
UniCare
Attn: Medical Director, Medical Operations Management
233 S. Wacker Drive
Suite 3900
Chicago, IL 60606
The Medical Operations Management department and the physician reviewers/medical directors use Milliman Healthcare Management Guidelines and the company's Medical Policy and Technology Assessments to support benefit decision making regarding medical necessity and appropriateness of care under the member's certificate of coverage. Although a particular service may be medically necessary, coverage of the service may be excluded based on specific limitations or exclusions contained in the member's Certificate of Coverage. You may receive the criteria used to make decisions by contacting the Medical Operations Management department at the address above. The Medical Policies are also available through the UniCare website at www.unicare.com; click on "Provider" and then "Medical Policy."
For appeals of benefit determinations based on medical necessity/appropriateness or investigational/experimental procedures/services, Indiana and Illinois state law provides UniCare HMO members with the right to an independent external review. For these reviews, the health plan uses various organizations, including Medical Care Ombudsman Program (MCOP), Hayes, Care Advantage, and CORE (Peer Review Analysis).
