PIH Health Physicians IPA
Utilization Management Communication Services
The MSO provides access to staff for members and practitioners seeking information about the UM process and the authorization of care.
Staff are available at least eight hours a day during normal business hours for inbound collect or toll-free calls regarding UM issues
The MSO uses any of the following methods for after-hours communication, as appropriate:
Staff can receive inbound communication regarding UM issues after normal business hours.
Communications received after normal business hours are returned on the next business day and communications received after midnight on Monday–Friday are responded to on the same business day.
Staff are identified by name, title and organization name when initiating or returning calls regarding UM issues.
TDD/TTY services for members who need them.
Language assistance for members to discuss UM issues.
UM Decision Making
Decision making is based on appropriateness of care and service and existence of coverage.
PHP does not specifically reward practitioners or individuals for issuing denials of coverage, does not offer incentives to encourage denials, and does not encourage decisions that result in under-utilization.
PHP ensures independence and impartiality in making referral decisions that will not influence hiring, compensation, termination, promotion and any other similar matters.
The Medical Director or physician designee must hold a current/unrestricted California medical license to review all denials that are based on medical necessity utilizing information provided (e.g., patient records, conversations with appropriate physicians).