UM decision making is based only on appropriateness of care and service and existence of coverage. Financial rewards or incentives must not influence any utilization decisions. All denials must be strictly based on insufficient medical appropriateness or not a covered benefit. No rewards or incentives are given for issuing denials of coverage or service. To assure that the risks of under-utilization are considered, no rewards or incentives can be issued that will discourage appropriate care and services to the members.
The Utilization Management staff is available during business hours, 8:00AM-5:00PM PST for any questions by calling:
Main Business Phone: (714) 947- 8600
Toll Free Phone No: (800) 375 – 4692
For Hearing Impaired: 711 California Relay Service
Language Assistance available upon request.
UM Criteria used in decision making can be obtained by contacting the UM Department at (714) 947-8600.