Members have the right to request a Medicare Part C Determination either verbally or in writing.

how utilization management works

There are times when your condition may require services and procedures not available in your Primary Care Physician’s (PCP) office. Your doctor may wish to order additional testing, treatment or evaluation by a Specialist, which may require pre-authorization.

REFERRAL AUTHORIZATION REQUEST

Your physician will fill out a form called a Referral Authorization Request, and forward it to Universal Care Medical Group's Utilization Management Department or your Contracted Medical Group (CMG) for review by a special committee of doctors. Under most circumstances, your PCP will arrange for services from a specialist within Universal Care Medical Group's extensive network of specialists.

The Referral Authorization Request is reviewed using specific criteria for determining medical necessity, based on the most current information regarding your medical condition and treatment methods. A decision is made to either approve or deny the request, or recommend alternative treatments. If a decision cannot be made based upon the medical documentation presented, additional information may be requested before a decision is made.

• UM decision making is based only on appropriateness of care and service and existence of coverage.
• Universal Care Medical Group does not specifically reward practitioners or other individuals for issuing denials for coverage of care.
• Financial incentives for UM decision-makers do not encourage decisions that result in under-utilization.

WHEN A REFERRAL AUTHORIZATION REQUEST IS APPROVED

When a requested authorization is approved, you will be referred to the appropriate specialist within the participating Medical Group. However, if the specialist and/or service is not available from any participating physician within the Universal Care Network, you will be referred to a non-participating physician practicing in the appropriate specialty.

WHEN A REFERRAL AUTHORIZATION REQUEST IS DENIED

If Utilization Management denies an authorization request, you may initiate an appeal. In addition, your Physician may appeal any denied authorization request on your behalf by submitting a detailed explanation of the medical necessity of the request, and supplying additional supporting medical information.   Upon review, if the appeal is denied, you and/or your physician may further appeal the decision. An Appeals Committee that consists of representatives who were not previously involved in the first level appeal decision will review the case.   In addition, at least one practitioner in the same or similar specialty that typically manages the medical condition, procedure, or treatment will be involved in making the appeals decision.   You and/or your physician also has the opportunity of appearing before the Appeals Committee to present the case.   Once a determination is made, the Appeals Committee will send written confirmation of its decision to your home and to your physician.

TO OBTAIN CRITERIA OR FILE AN APPEAL

The Committee utilizes specific criteria to determine the medical necessity of an authorization request.  You are entitled to a copy of the criteria used by the committee to review your request for a specific service.  To obtain criteria, even before a denial, please contact Universal Care Member/Patient Medical Group's Services Department at (800) 635-6668 and a Representative will assist you. To file an appeal, please contact your health plan.