HMO authorizations and referrals

For Members

Utilization management (UM) and case management overview

As a member of the UCI University Physicians & Surgeons Medical Group, you have the right to:

• Receive information about UCI University Physicians & Surgeons Medical Group, its services, providers and member rights and responsibilities.
• A discussion of medically necessary or appropriate treatment options for your condition regardless of costs or benefit coverage.
• File a complaint about the care or services you've received at UC Irvine Health or by one of the UCI University Physicians & Surgeons Medical Group providers by calling your Health Plan's Member Service Department

To speak to a nurse case manager or request assistance for your care, please call 714-509-2001, option 3.

Policies:

• The utilization management department reviews all requests for medical necessary and with adherence to contractual agreements
• There are no financial incentives for any decision makers within Utilization Management to encourage denials that may result in under-utilization
• UCI University Physicians & Surgeons does not sub-delegate any decision-making to any other entity
• All decisions are communicated to the requesting provider via EPIC or EZ Cap and members are notified of the decision via UCI Health MyChart or through mail

For Physicians

If you're a physician, you will find resources by clicking the drop-down below. 

UM criteria

UM decision-making is based only on appropriateness of care and service and existence of coverage. One of the primary purposes of utilization review is to determine the medical necessity of services requested.

Except where any applicable law or regulation requires a different definition, “Medically Necessary” or “Medical Necessity” shall mean health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are

(a) in accordance with generally accepted standards of medical practice;

(b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered defective for the patient’s illness, injury or disease; and

(c) not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors.

UM criteria are available to the member, practitioner and public by contacting our office at 714-509-2001. The team uses objective, evidenced-based criteria and guidelines for clinical review and UM decision making.