Quality & Medical Management



Criteria Availability

McLaren Health Plan's Utilization Management Program is structured to deliver fair, impartial and consistent decisions regarding health services. There are industry standard written criteria that are used when determining if health services are medically necessity. The criteria used in the decision making are available to you upon request by calling the Medical Management Department at (888) 327-0671 or (810) 733-9722.

Behavioral Health services are not subject to any medical necessity review at this time.

Incentives 

Utilization decision-making is based only on appropriateness of care and service and existence of coverage. We do not specifically reward practitioners or other individuals for issuing denials of coverage, service or care. Nor are there financial incentives for utilization decision makers to encourage decisions that result in under utilization.