TNPR’s UM decision making is based only on appropriateness of care and service and existence of coverage. TNPR uses local and national Medicare coverage guidelines, the member’s Health Plan designated Clinical Practice Guidelines, or if none applicable will use Apollo Clinical Guidelines to support benefit determinations related to medical necessity and investigational/experimental services.
For any medical necessity Non-Certifications, the Medical Director shall make an attempt to contact the requesting provider for peer-to-peer consultation. Applied Clinical Guidelines are available in both electronic and hard copy format. If a provider would like a copy of a guideline they may contact their assigned Provider Relations Representative and a copy will be provided.
TNPR does not specifically reward practitioners or other individuals conducting utilization review for issuing recommendations for denial of coverage or services. UM decision makers do not get any financial incentives for UM decisions that result in under-utilization.