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. 

For provider offices to send authorization requests, please fax to Utilization Management at 800-299-8780.

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.

California Commercial Claims

1. Contracted Paid/Denied Claims:

Under the Knox Keene Act, an eligible member to whom services were provided shall not be liable for any portion of the bill, except for applicable cost share, which may include deductible, co-insurance and/or copayments. The contracted provider should not bill the member or attempt to collect against the member, unless the member was not eligible at the time the services were rendered or non-emergency services were not authorized and/or directed by the participating medical group or primary care physician.

Pursuant to the Knox Keene Act of the State of California, the enrollee to whom prior approved services were provided is not liable for any portion of the bill, except for co-payments, deductibles, other cost sharing components, or non-covered benefits as defined in the enrollee’s Evidence of Coverage documents.

In the event the member appeared eligible no more than 72 hours prior to services being rendered and an authorization or eligibility is provided that the specific provider relied upon to render services and the member later appears ineligible on date of services, Knox-Keene requires that the provider and member be held harmless and you cannot recover payment.

2. Non-Contracted (these are all non-ER services)
1. Paid Claims: For dates of services on or after July 1, 2017; non-contracted providers may NOT balance bill a member for non-emergency services when covered services are rendered in a Participating Facility. In the event UCI University Physicians & Surgeons elects to use a non-participating Facility and UCI University Physicians & Surgeons does not enter into a Letter of Agreement that protects the member, all authorized services for non-emergency providers must be processed at Reasonable & Customary charges minus the member’s applicable cost-sharing.

2. Denied Claims: You may file a written appeal to UCIUPS, P.O. Box 450, La Verne, CA 91750 with a clear & concise reason for questioning/disputing the denial decision.

3. PDR Process (Contracted & Non-Contracted Emergency Services Claims)

Under AB1455 if you feel there is an error in payment, you may dispute in writing to:  UCIUPS, P.O. Box 450, La Verne, CA 91750. A complete description of the dispute process can be found here. 

Pursuant to California Code of Regulations Title 28, Sections 1300.71 and 1300.71.38, a provider may file a written dispute to: UCI University Physicians & Surgeons to challenge, appeal, or request for a reconsideration on a claim(s) that has been denied, adjusted, or contested.

Provider Disputes must be filed to UCI University Physicians & Surgeons within 365 days from the last date of written notification that led to the dispute. For instructions and forms for submitting a dispute, go to our website or contact our Customer Services Department at (714) 509-2001.

The dispute request must include the following information:                                                                                                    

1. Name address and phone number of the provider of service;
2. Provider's tax id number
3. Patient name
4. Insurer's information
5. Date of service
6. A complete and accurate explanation of the issue supporting documentation including copies of claims, claim number, medical records, or supporting documentation to challenge reports, as necessary, from the initial adverse determination. 

4. Non-Emergency Services Independent Dispute Resolution Process (AB 72 IDRP)

The law requires that the Department of Managed Health Care conduct an independent dispute resolution process (AB 72 IDRP) that allows a non-contracting provider who rendered services at, or as a result of services at, a contracting health facility, or a payor, to dispute whether payment of the specified rate was appropriate. Once a non-contracting provider or payor submits an AB 72 IDRP Application, the opposing party is required by law to participate in the AB 72 IDRP. AB 72 does not apply to emergency services and care.

Eligible Claims

Eligible claim disputes are those disputes that are subject to DMHC jurisdiction and meet all of the following criteria:

• The disputed claim must be for services rendered on or after July 1, 2017.
• The disputed claim must be for non-emergency services. If there is an unresolved dispute as to whether the health care service(s) at issue is non-emergent, the claim does not qualify for the AB 72 IDRP.
• The disputed claim must be for covered services provided at a contracting health facility, or provided as a result of covered services at a contracting health facility, by a non-contracting individual health professional.
• The non-contracting provider has completed the health plan or payor’s Provider Dispute Resolution (PDR) process within the last 365 days.
• The non-contracting provider is not a dentist.
• The payor is not a Medi-Cal managed health care service plan or any other entity that enters into a contract with the State Department of Health Care Services

For more information or to submit a dispute under the IDRP process, please go the California Department of Managed Health Care’s website.

 View full PDR Form.

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