Affirmative Statement

Medical Necessity (UM) Review

ASH and its affiliates affirm that:

• Clinical utilization decision-making is based on evaluation of submitted clinical information and adopted clinical standards of practice, and is solely for the purpose of determining the appropriateness and medical/clinical necessity of clinical care and services;
• Clinical Services Managers, Practitioners, or other individuals who make clinical utilization decisions are not rewarded or given other incentives to withhold, delay, or not approve medically/clinically necessary treatment/services;
• Clinical Services Managers and the Clinical Services Management Programs and policies which support them, do not contain inappropriate financial incentive programs that encourage underutilization;
• Clinical decisions made by Clinical Services Managers are non-discriminatory of any personal characteristics of the practitioner or member;
• Practitioners are ensured independence and impartiality in making referral decisions that will not influence: 
  -   Hiring
  -   Compensation 
  -   Termination 
  -   Promotion, or 
  -   Any other similar matters

ASH Clinical Quality Evaluators are not permitted to interfere with the referral process as it relates to patient care.

ASH and its affiliates facilitate the delivery of appropriate evidence-based clinical care to our members. We also monitor the impact of our clinical management program to detect and correct potential under- and over- utilization of services.