Utilization Management Policy

Disclosure Notice

Providence is delegated the responsibility for Utilization Management from contracted managed care (HMO) health plans. Providence follows the clinical guidelines set forth by Medicare and contracted health plans. The guidelines provided are used by Providence Medical Foundation 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 plan. In situations there is no available guidelines from the health plan, the delegated entity may adopt internal coverage policies approved by the health plans. Adopted internal coverage policies will comply with CMS guidance (refer to CMS Manual Chapter 4 section 90.5) MCM Chapter 4 (cms.gov) and are updated based off evidence-based guidelines and research. They are publicly accessible under Internal Coverage Guidelines.

  • Providence Medical Foundation will disclose a list of network providers to members, upon request.
  • Utilization Management medical clinical guidelines are disseminated 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.

Prior Authorization

To help facilitate greater transparency regarding Providence’s referral and prior authorization process, we are publishing a list of services that require prior authorization. This list includes services, procedures, medical equipment and drugs that require review for medical necessity prior to the services being rendered.

Referrals for services that require prior authorization must be submitted in order for authorization to be granted or denied. Prior authorization is required for payment when claims are submitted. During the medical review process for prior authorization, additional information may be requested. Providence’s Utilization Management and/or Claims departments will reach out to the requesting medical offices and service providers as needed. Some of the services, procedures, medical equipment and drugs on the list below may be the responsibility of our health plan partners. These services still require referral submission and will be shared with or directed to our health plan partners as appropriate.

For Cal-Optima members, medication prior authorizations are based on the Medi-Cal Prior Authorization Required List that is updated regularly here: Prior Authorizations.

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.