Utilization Management

HealthSmart MSO’s UM Department expedites request for authorizations and coordinates with the clients Medical Directors the fundamental practice of managed care. We strive to keep referrals within our clients contracted network. Physician profile referral statistics and hospital bed days reported monthly gives Our Clients a current overview of their UM activities. The Case Manager plays an important role in the monitoring, tracking and implementation of the utilization and quality of patient care process. More importantly, Case Management carefully monitors patients’ status on a daily basis. HealthSmart MSO’s IPA’s have contracted hospitalists to assist PCPs in inpatient admission, which further enhances the quality and coordination of care to our members.

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 are available to the public upon request. Requests may be made by contacting the UM Department at (714) 947-8600.
Click here to view the Clinical Criteria Hierarchy