WHA encourages its practitioners to practice open physician-patient communication and to freely discuss available treatment options, including medication treatment options, with their patients regardless of the patient's benefit coverage limitations. Practitioners shall not be penalized for discussing medically necessary or appropriate care and the available options with their patients.

Care and Treatment Review

Coverage Decisions

WHA's physician reviewers make coverage decisions related to appropriateness of care and services using available medical information about the patient and criteria that are based on recognized standards of medical practice. During these reviews, health plan benefits and individual circumstances of the patient are also considered.

Financial incentives or compensation are not linked to these decisions or to the withholding of care. If you would like to learn more about WHA's utilization management processes or receive information about the criteria or guidelines used by WHA to make care and treatment decisions, please contact WHA's member services department.

UM Criteria

The criteria primarily used by WHA to make medical necessity decisions are Milliman Care Guidelines and Hayes, Inc.'s New Technology Assessment & Experimental Treatment Guidelines. If you would like to receive excerpts or copies of clinical criteria currently used by WHA to make utilization management decisions on a particular subject matter or desire information about WHA's pharmaceutical management procedures, please contact WHA's member services at 916.563.2250 and ask for the medical management department.


Last Reviewed January 2015