Argus Dental & Vision, Inc.’s (Argus) decisions regarding the provision of health care services are based solely on appropriateness of care and services and the existence of coverage. Argus will be fully compliant with the Centers for Medicare and Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA) guidelines as it applies to the Incentives in Decision-Making Process.
Argus distributes a statement to all practitioners, providers, and employees who make Utilization Management (UM) decisions, affirming the following:
A. UM decision-making is based only on appropriateness of care and service and existence of coverage.
B. The organization does not specifically reward practitioners or other individuals for issuing denials of coverage.
C. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.
Additionally, Argus does not use incentives to encourage barriers to care and service, and does not make decisions regarding hiring, promoting or terminating its practitioners, employees, or other individuals based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits.