Utilization Management Disclosure

At Community First Health Plans, it is not a condition of employment or part of the evaluation process to base performance ratings, allow compensation or financial incentives for:

• The number of adverse determinations
• Limitations on lengths of stay, benefits, services, or charges
• The number or frequency of telephone calls or other contacts with health care providers or patients
• To encourage decisions that result in under-utilization

Utilization Management decision-making is based only on appropriateness of care, service, and existence of coverage.

Members who have questions or who are in need of assistance regarding the Utilization Management process may call Community First Health Plans at:

Providers with questions regarding the Utilization Management Process, or who wish to obtain a copy of the criteria used in the decision making process, may call the Population Health Management Resolution Unit at (210) 358-6050.

You may also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https:/ocrportal.hhs.gov/ocr/portal/lobby.jsf.