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Utilization Management

Utilization Management Program Overview

The purpose of the utilization management program is to promote fair, impartial and consistent utilization decisions and coordination of care for health plan members. The Sunshine Health utilization management program serves to:

  • Ensure confidentiality of personal health information
  • Initiate process improvement activities to enhance utilization management practices
  • Make evidence-based decisions that take into consideration medical necessity, appropriateness and availability of benefits
  • Objectively and consistently monitor and evaluate the delivery of high quality and cost-effective services

Sunshine Health does not discriminate in the provision of services based on an individual’s race, color, national origin, sex, age or disability, including to:

  • Deny, cancel, limit or refuse to issue or renew a Sunshine Health insurance plan or other Sunshine health coverage
  • Deny or limit coverage of a claim, or impose additional cost sharing or other limitations or restrictions on coverage
  • Exclude or limit categories of services related to gender transition (for the Medicaid and CWSP products, this follows the benefits established by AHCA)
  • Use discriminatory marketing practices or benefit designs

All utilization management employees are required annually to sign an affirmative statement regarding compensation. Compensation or incentives is prohibited to Sunshine Health staff or any subcontractor or vendor performing utilization management on behalf of Sunshine Health based on the following circumstances:

  • Amount or volume of adverse determinations
  • Reductions or limitations on lengths of stay, benefits or services
  • Frequency of telephone calls or other contacts with health care practitioners or patients

Utilization management policies and processes serve as an integral component to prevent, detect and respond to fraud, waste and abuse among practitioners and members. The utilization management department works closely with the compliance officer, risk Sunshine Health MMA, LTC and CWSP Provider Manual © 2018 Sunshine Health 29 manager and Centene Corporation’s special investigation unit to resolve any potential issues that are identified.