Utilization Management

At the time of your visit, we require payment for deductibles, co-payments and non-covered services. To request special payment arrangements, or to see if you are eligible for our charity care policy, contact our Patient Financial Services Department.

For services where your health plan requires prior authorization, our Utilization Management Department follows up-to-date testing and specialty care indication guidelines to authorize care in accordance with your health plan. Utilization Management is comprised of healthcare professionals who are trained in the policies and procedures developed by the health plans and regulatory agencies that will be used when a prior authorization is needed for a service your physician has ordered.

The Dignity Health Medical Foundation Utilization Management Program description and contracts specifically prohibit the use of incentives for its utilization management programs or coverage determinations. Bonuses or incentive pay are not used in any way to influence a practitioner’s decision to withhold, delay or deny necessary medical services. Any financial incentives used for Utilization Management or Behavioral Health decision makers are not linked or used to encourage decisions that result in under utilization.

Utilization management description

(a) A plan shall disclose or provide for the disclosure to the director and to network providers the process that the plan, its contracting provider groups or any entity with which the plan contracts for services that include utilization review or utilization management functions, uses to authorize, modify, or deny health care services under the benefits provided by the plan, including coverage for subacute care, transitional inpatient care, or care provided in skilled nursing facilities. A plan shall also disclose those processes to enrollees or persons designated by an enrollee, or to any other person or organization, upon request. The disclosure to the director shall include the policies, procedures and the description of the process that are filed with the director pursuant to subdivision

(b) of Section 1367.01. (b) The criteria or guidelines used by plans, or any entities with which plans contract for services that include utilization review or utilization management functions, to determine whether to authorize, modify or deny health care services shall:

1. Be developed with involvement from actively practicing health care providers.
2. Be consistent with sound clinical principles and processes.
3. Be evaluated, and updated if necessary, at least annually.
4. If used as the basis of a decision to modify, delay or deny services in a specified case under review, be disclosed to the provider and the enrollee in that specified case.
5. Be available to the public upon request. A plan shall only be required to disclose the criteria or guidelines for the specific procedures or conditions requested. A plan may charge reasonable fees to cover administrative expenses related to disclosing criteria or guidelines pursuant to this paragraph, limited to copying and postage costs. The plan may also make the criteria or guidelines available through electronic communication means.

(c) The disclosure required by paragraph (5) of subdivision (b) shall be accompanied by the following notice: "The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract."

Additional Information for Patients

(Mercy Medical Group and Woodland Clinic patients)