Utilization Management Notifications

When UMBH Makes a Decision

In making a decision about authorizing behavioral health care, the only factors UMBH considers are whether the care or service is appropriate and whether coverage exists for the care or service. UMBH never rewards practitioners or other individuals involved in making decisions for denying care or service. There are no financial incentives for any UMBH employee or representative that would encourage underutilization of behavioral health care or services.

What to Do If You Disagree with a Decision

University of Miami Behavioral Health uses a team of behavioral health care professionals to ensure that members get the treatment they need and that it is consistent with their health insurance benefits. Occasionally, you may disagree with our decisions. UMBH has an appeals process that can be used if you believe we have not made the correct decision. All appeals are reviewed by psychiatrists or other doctoral level behavioral health clinicians who were not involved in the original decision. In addition to this internal appeals process, you have the right to appeal decisions to an external review body. In the State of Florida, the Agency for Health Care Administration (AHCA) conducts external appeals.

To start an external appeal, you must notify UMBH in writing that you want to appeal the case to AHCA. The written notification must be submitted within thirty (30) days of the date you received notification of UMBH’s internal appeal decision. For additional information about external appeals, contact UMBH Compliance Department at 1-800-294-8642.

How to Contact a Peer Reviewer 

If clinical review determination results in a denial, practitioners have the opportunity to discuss this with the Physician Reviewer who rendered the decision. When practitioners are notified of the authorization decision, they are provided with the UMBH telephone number, 1-800-294-8642 to contact the Physician Reviewer. The Reviewer is available for discussion and/or to receive additional information that may impact the authorization decision. This discussion does not replace or alter the right to appeal the authorization decision.