In accordance with NCQA UM Standard 11.5, I have recieved and understand the following:
1.UM decision making is based only on appropriateness of care, service and existence of coverage.
2. The physicians or other individuals conducting utilization review for denials of coverage or services are not compensated for denials and/ or encourage barriers to care or service.
3. Financial incentives for UM decision makers do not encourage denials of coverage or service.
4. Incentives are not used to reward inappropriate restriction of care.
5.Special concern must be kept in mind regarding the risk associated with under-utilization.6.Physicians, employees and other individuals conducting utilization review are ensured independence and impartiality in making referral decisions that will not influence Hiring, Compensation, Termination and Promotion.
Whether you have questions or are experiencing difficulties with your insurance, you may contact our Member Services representative at (626) 457-5579 Or Dial Toll Free (877) 457-4377. Member services is open Monday through Friday 8:00am – 5:00pm.
CRITERIA USED FOR UM DECISION MAKING IS BASED ON MCG Health, LLC
Members who are deaf or hard of hearing can access TDD/TYY Services directly by calling California Relay Service (CRS) by dialing 711.
For members that prefer immediate assistance in their mode of communication but don't have a preferred provider, DDTP numbers are available and can be dialed toll free.
Utilization Management staff is available Monday - Friday 8:00am - 5:00pm on any questions regarding the UM process.
Please call (626) 457-5579 Or Dial Toll Free (877) 457-4377 and request to speak to the UM department.