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Utilization Management Review Criteria

Criteria are established and periodically evaluated and updated with appropriate involvement from physician members of the Trillium Utilization Management Committee. Utilization review decisions are made in accordance with currently accepted medical or healthcare practices, taking into account special circumstances of each case that may require deviation from the norm in the screening criteria.

Please note that Trillium takes steps to ensure that decisions regarding the provision of healthcare services are based solely on appropriateness of care and services, and the existence of coverage. To that end, Trillium has policies in place to ensure:

  • Decision-making is based only on appropriateness of care and service, and the existence of coverage
  • The organization does not specifically reward practitioners or other individuals for issuing denials of coverage or service care
  • Financial incentives for decision-makers do not encourage decisions that result in underutilization

A member or the treating providers may obtain the criteria used to make a specific adverse determination by contacting the Prior Authorization Department at 1-844-867-1156 (TTY: 711).