Utilization Management Policy
Procedures and Criteria are Disseminated to Members Upon Request.
The materials provided to you are guidelines used by the medical group to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and benefits covered under your contract. Those are guidelines and do not constitute the standard of care.
- Providence Saint John's Health Center will disclose a list of network providers to members, upon request.
- Utilization Management medical clinical guidelines will be disclosed to members and practitioners, upon request.
- All Utilization Management decisions are based on appropriateness of care and service.
- Providence Saint John's Health Center/Foundation does not compensate practitioners for individual denials.
- Providence Saint John's Health Center/Foundation does not offer incentives to encourage denials.
- Providence Saint John's Health Center/Foundation does not have the financial incentives that would encourage decisions that would impact under/over-utilization of care, service or available member benefits.
For questions or concerns that are related to a referral that your provider has submitted, patients can telephone our main Utilization Management number, 855-359-6323. Hearing or speech-impaired members (TTY users) can call 711 relay services. Collect calls are accepted for patient referral matters, and Spanish speaking staff members are available.