Affirmative Statement

Separation of Medical Services from Fiscal and Administrative Management and Confidentiality Agreement

As a participant of the MemorialCare Select Health Plan Quality and Utilization Management (UM) activities, I acknowledge MemorialCare Select Health Plan’s separation of medical services from fiscal and administrative management that requires:

1. UM decisions based only on appropriateness of care and service and existence of coverage;
2. No specific rewards to providers/practitioners or other individuals for issuing denials of coverage or service care;
3. No financial incentives for UM decisions decision makers for decisions that result in underutilization;
4. Confirmation that consumer healthcare is no compromised by financial influences;
5. Ensured independence and impartiality in making referral decisions that will not influence:

  • Hiring;
  • Compensation;
  • Termination;
  • Promotion;
  • Any other similar matters.

As a participant in MemorialCare Select Health Plan Utilization Management (UM)activities, I recognize that confidentiality is required for UM processes. Therefore, I agree to respect and maintain the confidentiality of all discussions, records, and information generated in connection with UM activities, and to make no disclosure of such information except to persons authorized to receive it.


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