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Maine.gov > PFR Home > Insurance Regulation > Consumer Information > All Brochures > Utilization Review Requests, Decisions, and Appeals

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Utilization Review Requests, Decisions, and Appeals

Health Guide Ranking Utilization Review Requests, Decisions, and Appeals Independent External Review
Health Guide Complaints Health Guide Contacts Health Guide

 

Four performance areas are presented in this Interactive Guide. Select from the toolbar above to view each of the comparative charts. Below each chart is a description on how to read and understand the results.

Initial (First-Time) Utilization Review Requests, Decisions, and Appeals (January 2010 - December 2010)

Insurer/HMO Number of First Time UR Requests Made to the Insurer/HMO Number of Decisions Insurer/HMO Made to Deny First Time Requests for Services for the Covered Person Number of Decisions Made to Deny First-Time Requests for Services that were Appealed by the Covered Person Number of First-Time UR Denials that were Reversed by the Insurer/HMO when the Covered Person Appealed - Reversal Rate is also shown
(see explanation below)
Aetna Health, Inc.          
Anthem Health Plans of Maine 12,610 2,121 1,177 501 43%
CIGNA HealthCare of Maine, Inc. 40 17 0 0 0%
Connecticut General Life Insurance Company 20,774 2,054 83 41 49%
Guardian Life Insurance Company of America          
Harvard Pilgrim Health Care, Inc. 2,262 311 45 21 47%
John Alden Life Insurance Company          
MEGA Life & Health Insurance Co          
Securian Life Insurance Company
(Dental Coverage Only)
         
Trustmark Life Insurance Company          
United Healthcare Insurance Company          

 


UTILIZATION REVIEW

Utilization Review (UR) is a program used in managed care plans that is designed to reduce unnecessary medical inpatient or outpatient services. An individual or organization, on behalf of an insurer, reviews the necessity, use, appropriateness, efficacy or efficiency of health care services, procedures, providers, or facilities.

An appeal on an unfavorable UR decision occurs when a consumer asks an insurer to reconsider its refusal to pay for a medical service that the insurer considers not medically necessary. Insurers are required to have medical professionals review the appeals that they receive. Some common UR issues involve whether a hospital admission is necessary based on the medical condition, how long a stay in the hospital should be, and medical procedures.

A reversed UR appeal takes place when the health insurer decides in favor of the consumer and reverses its initial decision that it would not cover a service or procedure. Reversal Rate is the percentage of insurer/HMO decisions that were made against consumers and then were reversed after an additional review. For example, a 50% reversal rate shows that in 5 out of 10 appeals, the insurer/HMO changed its initial decision in favor of the covered person.


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Last Updated: August 22, 2012