Utilization management decision making is based on review of the appropriateness of care and service. Requests for coverage are reviewed to determine that the service is a covered benefit under the terms of the patient’s plan and is being delivered consistent with established guidelines. In the event a request for coverage is denied, the patient (or a physician acting on behalf of the patient) may
appeal this decision through the appeal process defined by the health plan. In addition, after completing the appeal process, the patient may request a review of certain denials by an external review organization that uses independent physician reviewers. LLUHC does not specifically reward its employees conducting utilization reviews for issuing denials of coverage or service care. The utilization management decision makers do not receive financial incentives which would encourage decisions that result in underutilization but are trained to focus on the risk of underutilization. Practitioners are ensured independence and impartiality in making referral decisions that will not influence: hiring, compensation, termination, promotion, or any other similar matters. Referral decisions will not compromise member healthcare. However, LLUHC policies do not preclude the use of appropriate incentives for fostering efficient, appropriate care. The guidelines used by LLUHC utilization management include CareWeb QI (a web-based product from MCG – formerly Milliman Care Guidelines), Medicare coverage guidelines, Health Plan policies and coverage guidelines, California Department of Health Care Services (DHCS) coverage guidelines, Apollo Managed Care guidelines and the LLUHC established clinical practice and referral guidelines. Use of criteria when reviewing requested services will follow the hierarchy established by CMS, DMHC and/or health plans. All guidelines, the Utilization Management policies and the 2021 Utilization Management Plan are available for review by contacting the Managed Care office at 909-651-1700 or extension 21700 or may be viewed on the PolicyTech webpage tab on the One Portal. If you have any questions regarding denial decisions, you may contact Physician reviewers by calling 909-651-1743. CA Health & Safety Code § 1363.5(a) and § 1367.01(b)
The managed care staff is available to help you during normal business hours: Monday through Thursday 8am to 5pm and Friday 8am to 4pm at 909-651-1700. The office is closed on weekends and holidays
1. TDD/TTY Services for the deaf are offered. Deaf, hard of hearing members may access the
UM Department through the phone system by dialing 711.
2. Language assistance for members to discuss UM issues is available through coordination of
interpreter services with the health plans. (NCQA UM3)
