HMO Authorizations and Referrals
Our Managed Care team can answer questions such as:
- What your insurance policy may cover
- The status of an authorization
- Questions on billing and reimbursement
We're here to help if you receive primary care through UCI University Physicians & Surgeons through these contracted health plans:
Commercial HMO plans
- Anthem Blue Cross
- Blue Shield of California
- Cigna
- Health Net Commercial and Blue & Gold under both PPG 1 (3208) and PPG 2 (3854)
- United HealthCare
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 (please note):
- 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
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.
The hierarchy for referral determination guidelines follows the sequence below:
A. Federal law (e.g., National Coverage Determinations (NCD), Local Coverage Determinations (LCD) and Medicare Coverage Articles for programs under federal oversight such as Medicare)
B. State law/guidance (e.g., when state requirements override or exceed federal requirements)
C. Benefits
D. Individual Health Plan policy
E. National recognized decision-support tool MCG® or other nationally recognized decision-support tool
F. In the case of no guidance from A-D, the Medical Director will consider any of the following:
- Reports from peer-reviewed medical literature, where a higher level of evidence and study quality is more strongly considered in determinations
- Professional standards of safety and effectiveness recognized in the US for diagnosis, care or treatment
- Nationally recognized drug compendia resources such as Facts & Comparisons®, DRUGDEX®, and The National Comprehensive Cancer Network® (NCCN®) Guidelines
- Medical association publications
- Government-funded or independent entities that assess and report on clinical care decisions and technology such as the Agency for Healthcare Research and Quality (AHRQ), Hayes Technology Assessment, Up-To-Date, Cochrane Reviews, National Institute for Health and Care Excellence (NICE), etc.
- Published expert opinions
- Opinion of health professionals in the specialty area involved
- Opinion of attending provider in case at hand.
Contact Managed Care
By phone: 714-509-2001
- Claims and billing inquiries: Option 1
- Member services: Option 2
- Authorization questions: Option 3
Claims submission
UCI University Physicians & Surgeons
P.O. Box 450
La Verne, CA 91750
Urgent care locations
Health plan translation services
All HMO patients in California can access their health plans for interpreting/translation services at all points of care while receiving healthcare services.
The expert, compassionate team in the UCI Health Language Services Program can assist our patients with easy, on-site translation assistance.
You can also contact your plan at the following numbers to receive language assistance from your plan.
- Anthem Blue Cross: 800-331-1476
- Blue Shield of California: 510-607-2000
- Cigna: 302-797-3100
- Health Net: 800-522-0088
- United HealthCare: 866-801-4409