Utilization Management Policy
Procedures and criteria are disseminated to members on request.
Disclosure Notice
The materials provided to you are guidelines used by the medical group
to authorize, modify or deny care for persons with similar illnesses or
conditions. Specific care and treatment may vary depending on individual
need and benefits covered under your contract. Those are guidelines and
do not constitute the standard of care.
- Providence Medical Foundation will disclose a list of network providers
to members, upon request.
- Utilization Management medical clinical guidelines will be disclosed to
members and practitioners, upon request.
- All Utilization Management decisions are based on appropriateness of care
and service.
- Providence Medical Foundation does not compensate practitioners for individual denials.
- Providence Medical Foundation does not offer incentives to encourage denials.
- Providence Medical Foundation does not have the financial incentives that
would encourage decisions that would impact under/over-utilization of
care, service or available member benefits.
For questions or concerns that are related to a referral that your provider
has submitted, patients can telephone our main Utilization Management number:
855-359-6323. Hearing or speech-impaired members (TTY users) can call 711 relay services.
Collect calls are accepted for patient referral matters, and Spanish speaking
staff members are available.