Appropriate Utilization

ASH and its affiliates distribute an affirmative statement annually to all its contracted practitioners, providers, and staff regarding any incentive programs that may encourage inappropriate utilization.

ASH facilitates the delivery of appropriate evidence-based clinical care to members/insured and monitors the impact of its clinical care management program to detect and correct potential under- and over-utilization of services.

• ASH and its affiliates affirm that:
  • Clinical utilization decision-making is based on evaluation of submitted clinical information and adopted clinical standards of practice, and is solely for the purpose of determining the appropriateness and medical/clinical necessity of clinical care and services;
  • Practitioners or other individuals are not rewarded for issuing denials of benefit coverage or service care; and
  • Utilization decision-makers are salaried employees and do not receive financial incentives that result in under-utilization.

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