Provider Operations
Utilization Management & Claims
Prior authorizations, claims submission, and billing resources for all DWIHN network providers — including Medicaid, SUD, Autism, and HIDE-SNP lines of business.
Claims and authorization resources for all active DWIHN network providers.
Key Provider Operations
Authorization processing, claims management, and self-directed services support for every provider in the DWIHN network.
Prior Authorization
Submit and track service authorization requests across all four lines of business. 99% standard approval rate with average 3.2-day turnaround.
Claims Submission
Electronic and paper claims processing for Medicaid, SUD, Autism, and HIDE-SNP. Reconsideration support and billing guidance available.
Self-Direction
Support for providers delivering member-directed services. Work with Financial Management Service Agencies and understand your role in person-centered care.
Our Commitment
Utilization Management Affirmative Statement
All DWIHN, Crisis Service Vendors, and Access Center practitioners and employees who make Utilization Management decisions understand the importance of ensuring that all consumers receive clinically appropriate, humane and compassionate services.
- Utilization Management decision-making is based only on appropriateness of care, service, and existence of coverage.
- DWIHN, The Access Center, and Crisis Service Vendors do not reward practitioners or other individuals for issuing denials of coverage or service care.
- No physicians nor any other staff making UM decisions are rewarded for issuing denials of coverage or service or reducing the provision of care which is deemed medically necessary.
Questions about UM decisions?
Our UM team can assist with authorization questions, appeal processes, and clinical review inquiries.
Contact UM TeamMember-Directed Services
Self-Determination
As a provider within DWIHN, it is important to understand the principles of Self-Determination (SD) and how Self-Directing Services may impact your role in supporting members.
Self-Determination is the right of every DWIHN member to make choices about their own lives and services. Its core goals are to:
- Promote full inclusion in the community
- Increase members sense of self-worth and belonging
- Reduce isolation and segregation
The foundation of SD is choice, autonomy, competence, and connection — key elements of psychological well-being.
Self-directing services give members control over the services they receive and who provides them. Members can:
- Use an individual budget — the funds allocated in their Individual Plan of Service (IPOS) — to purchase authorized services and supports
- Hire providers of their choosing, whether in-network or out-of-network, as long as the provider meets Medicaid requirements
- Decide which services they want to self-direct — this could be one service, several, or all services in their IPOS
While members drive the decision-making, providers play a critical role in delivering high-quality, person-centered services within the self-direction model:
- Support Coordinators introduce and review self-directing options with members annually during Person-Centered Planning (PCP)
- Providers may be approached directly by members who wish to contract for services under their individual budget
- Providers must meet Medicaid standards and follow all requirements outlined in the member IPOS and the written agreement
- Payment for services will be processed through a Financial Management Service (FMS) Agency
Self-Determination Team
For questions about self-directing services, eligibility, or the process for becoming a self-direction provider.
Email SD TeamSelf-Direction
Working with Financial Management Service Agencies
Providers delivering services under a self-directed arrangement via a Direct Hire or Purchase of Service model will receive payment via the member's chosen FMS Agency.
These agencies manage issuing payments to providers on behalf of the member and maintaining records and ensuring compliance with Medicaid billing requirements.
Key Takeaways for Providers
Flexibility
Self-direction may bring opportunities to work with members in a more personalized, tailored way.
Compliance
You must meet all Medicaid provider qualifications — regardless of whether you are in or out of the DWIHN network.
Collaboration
Effective communication with the member, Support Coordinator, and FMS Agency is essential for success.
Get Involved
Self-Directing Services Welcome Meetings
What They Are
An opportunity to ask questions or seek general information about Self-Directing Services, discuss the implementation process, meet with families to review/sign SD Agreements, and get targeted training on goal statement/objective/intervention development.
Who Should Come
Support Coordinators, Case Managers, Members, Family of Members, or anyone with questions about Self-Directing Services.
Meeting Schedule
- Monday — 4:00 PM
- Tuesday — 1:00 PM
- Wednesday — 12:00 PM
- Thursday — 10:00 AM
To attend, reach out to the SD Team at Selfdetermination@dwihn.org.
Performance Data
Authorization Metrics
2025 utilization management performance data for DWIHN network providers.
Approvals
- Standard prior authorization approval rate99%
- Timeframe extensions approved0%
- Expedited authorization approval rate99%
Denials
- Standard denials1%
- Expedited denials1%
Appeals
- Standard requests approved after appeal32.6%
Timeliness
- Standard authorization average3.2 days
- Standard authorization median0 days
- Expedited authorization average16.5 hours
- Expedited authorization median11 hours
Billing & Claims
Claims Management
Claims Management processes claims for contracted and non-contracted providers. Claims are submitted electronically and via paper for services rendered. Claims are processed for four lines of business: Medicaid, Substance Use Disorder (SUD), Autism, and HIDE-SNP.
Claims personnel work closely with other units such as Office of Fiscal Management (Finance), Utilization Management, MCO, Quality, Compliance, and Information Technology to ensure a smooth process for paying out claims.
Claims Reconsideration
If a claim has been denied or requires reconsideration, download the reconsideration form and submit it to the Claims Unit.
Download Form (XLSX)
Marlena J. Hampton
Director of Utilization Management
Marlena J. Hampton leads the Utilization Management department, overseeing authorization reviews, level-of-care determinations, and the clinical review processes that ensure members receive the right care at the right time. With a background in clinical counseling and managed behavioral health, Marlena brings a person-centered approach to UM — working closely with providers, clinical teams, and MCO partners to remove barriers and support timely access to services.
Every authorization decision we make has a real person behind it. Our job is to make sure that person gets the care they need — without unnecessary delays or barriers.
Medical necessity criteria used in utilization review can be requested here: PIHPAuthorizations@dwihn.org
UM & Claims Support
Need help with an authorization or claim?
Our Utilization Management team can assist with denied authorizations, claims status inquiries, and billing questions. Reach out before timely filing deadlines.
