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Utilization management

Utilization management affirmative statement

Utilization management decisions are based only on appropriateness of care and do not include incentives or reward practitioners to encourage underutilization or denials of coverage. Hennepin Health will distribute and document its affirmative statement through the web or in an alternative form such as writing, fax or mailing when requested. Mechanisms for distribution will include one or more of the following: member services handbook, mailing to members, newsletter article, practitioner handbook, published on the internet and/or a focused mailing. The statements will be updated and reviewed annually.

Members have the right to an independent review regarding any utilization management decisions.

Patient protection

In accordance with the Minnesota Patient Protection Act, certain health services provided under the direction of your physician require prior Hennepin Health approval, including:

  • Home health care (registered nurse services, home health aide services, physical therapy, laboratory services, oxygen, durable medical equipment and related supplies)
  • Chiropractic services
  • Private-duty nursing provided by a registered or licensed practical nurse regardless of location
  • Accident-related dental services when services are required for treatment of accident-related injury to sound natural teeth
  • Prosthetic and orthotic supplies made necessary as a result of injury or sickness occurring while coverage under this contract is in force
  • Treatment of temporomandibular joint (TMJ) disorders except a single preliminary exam (diagnostic tests, evaluations, non-surgical treatments and surgical treatment)
  • Durable medical equipment

Standing referrals

Also in accordance with the Minnesota Patient Protection Act, you have the right to request a standing referral – written consent allowing you to see a specialist (for a chronic condition) more than once without having to get a new referral from your primary care clinic each time. A standing referral must be from your primary clinic, and state in writing all services to be provided and for how long. The specialist is not able to make additional referrals for services without permission from your primary care clinic.

Services requiring prior authorization

Certain services require prior authorization for Hennepin Health members. The prior authorizations document (DOC) outlines which services require prior authorization or notification to Hennepin Health. Providers are responsible for verifying eligibility and benefits before providing services to members.

Contact

If you have any questions regarding the above information, call Hennepin Health Member Services at 612-596-1036 (TTY: 1-800-627-3529), Monday through Friday from 8 a.m. to 4:30 p.m. For after-hour requests, a message can be left on the confidential voice mail and your call will be returned the following business day. Upon request, this information can be made available in an alternative format such as Braille, large print or audiotape.


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