Western Health Advantage’s Clinical Resources Department is responsible for determining health care services that are covered and payable under the health plan. Utilization management decisions are based on appropriately and consistently applying objective, written evidence-based criteria. Western Health Advantage provides a mechanism that ensures fair and consistent prior, concurrent, and retrospective medical decisions based on established protocols and pre-approved written criteria and review protocols or regulatory required criteria.
Insurance eligibility and benefits are verified first to make sure you have effective coverage. Your referral request is also checked to see if the specialty service you need will be provided by a WHA network provider. Experienced reviewers (nurses, pharmacists or doctors) then evaluate your individual situation and compare your relevant medical records against review criteria that are based on recognized standards of practice for your diagnosis. Using established medical criteria helps reviewers decide if requested services are appropriate and medically necessary, and they promote fair and consistent decisions. During these reviews, Plan benefits and individual circumstances of the patient are also considered. Financial incentives or compensation are not linked to these decisions or to the withholding of care.
Review criteria are based on sound clinical principles and treatment practices, and involve actively practicing board-certified specialists in their development. All criteria/guidelines used by WHA and its medical groups must be approved annually by WHA's Quality Committee and Board of Directors to make sure they are still appropriate and current.
For additional information, please see our Western Health Advantage Policy page.
