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Utilization Management

KOVA Healthcare, Inc. has a Utilization Management program to ensure that members have access to quality health care. The program utilizes a team of health care professionals to evaluate the
medical necessity of the services by using nationally recognized, evidence-based clinical guidelines and community standards. The decisions are based on the appropriateness of care and services
available to members within their contracted benefits. KOVA Healthcare affirms the following Utilization Management program practices:


  • Utilization Management decision-making is based only on the appropriateness of the care and services requested, the existing coverage and benefits available

  • Utilization Management staff are not rewarded or otherwise incentivized to issue denials of coverage of services

  • Utilization Management decision-making staff members do not receive financial incentives that encourage decisions resulting in underutilization

As a reminder to all associated practitioners, providers, enrollees, and employees that make UM decisions, the following statement is being distributed as required by our contracted plans:

Utilization Management decision-making is based only on the appropriateness of care and service. Universal Care dba KOVA Healthcare does not specifically award or compensate practitioners or other individuals conducting utilization reviews for issuing denials of care. Financial incentives for utilization management decision-makers do not encourage decisions that result in underutilization. All practitioners are ensured independence and impartiality in making referral decisions that will not influence hiring, compensation, termination, promotion, or any similar matters.

Clinical Issues Are Reviewed and Determined by Doctors


KOVA Healthcare receives numerous requests for authorization for coverage of medical services. If the review involves a clinical issue, no one other than a physician can make a determination to deny coverage for the services requested. In all instances, our physician reviewers and medical directors welcome direct contact with the treating physician to promote a dialogue regarding medical and/or hospital services that are requested.

Appropriate Care Is Facilitated Between KOVA Healthcare and its Members through the Following Guidelines:


  • Utilization Management decisions are based only on the appropriateness of care and service.

  • No person involved in the authorization process may receive compensation for denial of care.

  • No person involved in the authorization process may receive an incentive whether financial or non-financial, directly or indirectly to encourage denials.

  • The utilization process must include systems to monitor for over/underutilization of services. The process shall include analysis or monitoring reports, identification of issues, development of clinical care management plans, and evaluation of the actions.

Review Criteria

Criteria used for a specific review decision is made available to providers, members and the public upon request to KOVA Healthcare UM Department. For Peer to Peer review please contact KOVA Healthcare Department at (559) 207-3198

Review Criteria
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