Important information about utilization management

Our utilization management (UM) decisions are based on the appropriate care and service needed and the member’s coverage according to their health plan. We do not reward care providers or others for issuing coverage, service, or care denials. We do not make hiring decisions, promotions, or terminations based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. To access Medical Policies and UM Criteria, visit the Medical Policies & Clinical UM Guidelines page of our provider website.

To request a complimentary copy of our UM Criteria, please contact Provider Services at 844-396-2330. Care providers can discuss a UM denial decision with a physician reviewer by calling us toll-free at the number listed below. To access UM Criteria online, visit our website.

We are staffed with clinical professionals who coordinate member care and are available 24/7 to accept precertification requests. If you have questions or concerns regarding UM decisions, you can use secured voicemail during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues. You can submit precertification requests via:

• Availity Essentials: http://Availity.com (preferred method)
• Phone (including pharmacy requests): 844‑396‑2330
• Fax:
• Durable medical equipment, physical therapy, occupational therapy, speech therapy, pain management, home care, home infusion requiring nursing services, insulin pumps, hyperbaric treatment, or wound care: 866‑920‑8362
• All other inpatient and outpatient services: 800‑964‑3627
• Pharmacy prior authorization, including home infusion injectables, continuous glucose monitoring equipment, and diabetic supplies: 844‑490‑4876

If you have further questions about utilization decisions or the UM process, please contact Provider Services at 844-396-2330, Monday through Friday, from 8 a.m. to 5 p.m. PT.

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.