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DHMSO UM Affirmative Statement About Incentives

In alignment with health plan requirements and the National Committee for Quality Assurance (NCQA) Standards and Guidelines, DHMSO upholds a commitment to fair and ethical utilization management (UM) practices. All employees and physician reviewers involved in UM decisions adhere to the following principles:

• UM decision-making is based only on the appropriateness of care and service and the existence of coverage.
• DHMSO does not specifically reward practitioners or other individuals for issuing denials of coverage.
• Financial incentives for UM decision-makers do not encourage decisions that result in underutilization.

DHMSO affirms that no incentives are used to create barriers to care and service. However, appropriate incentives may be applied to support the efficient and appropriate delivery of healthcare services.

DHMSO remains dedicated to upholding the highest standards of integrity in UM decision-making, ensuring that all policies and practices prioritize patient well-being and align with industry best practices.

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