Utilization Management & Claims
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 of the same quality that one would expect for their child, parent, or spouse by affirming the following:
- Utilization Management (UM) 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
Self-Determination
Understanding Self-Determination and Self-Directing Services at DWIHN
As a provider within the Detroit Wayne Integrated Health Network (DWIHN), it is important to understand the principles of Self-Determination (SD) and how Self-Directing Services may impact your role in supporting members.
What Self-Determination Means for 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.
What Self-Directing Services Are
Self-directing services give members control over the services they receive and who provides them. Instead of relying solely on professionally managed service models, 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.
Provider’s Role in Self-Directing Services
While members drive the decision-making, providers play a critical role in delivering high-quality, person-centered services within the self-direction model. Providers should be aware that:
- 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’s IPOS and the written agreement.
Payment for services will be processed through a Financial Management Service (FMS) Agency, which manages payroll, invoices, and related financial transactions.
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 handle:
- Issuing payments to providers on behalf of the member.
- 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.
For more information or questions about self-directing services, contact selfdetermination@dwihn.org
Self-Directing Services Welcome Meetings
What They Are
Opportunity to ask questions or seek general information about Self-Directing Services, discuss the implementation process, meet with families to review/sign SD Agreements (understand responsibilities regarding being an employer), get target 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.
When
There are 4 meeting days available:
- Monday, 4 p.m.
- Tuesday, 1 p.m.
- Wednesday, 12 p.m.
- Thursday, 10 a.m.
Where
If you are interested in attending one of the sessions, please reach out to the SD Team at Selfdetermination@dwihn.org.
Resources
DWIHN offers a wide range of supports and services to help individuals with intellectual and developmental disabilities live with dignity, independence, and inclusion. Services are person-centered and designed to promote growth, community participation, and overall well-being.
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 MI Health Link.
Claims personnel works 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.
For questions regarding Claims, please contact:
pihpclaims@dwihn.org or call (313) 344-9099 (ask for Claims Unit)
For Claims correspondence, send mail to:
Detroit Wayne Integrated Health Network
707 W. Milwaukee St
Detroit, Michigan 48202
Attention: Claims Unit
For Claims Reconsideration: