Utilization Management Policies and Processes 

• UM Medical Necessity Criteria, including how to obtain or view a copy
• Policy prohibiting financial incentives for utilization management decision-makers
• Instructions on how to contact staff if you have questions about UM processes and triaging inbound calls specific to UM cases/issues
• Availability of, and the process for, contacting a peer reviewer to discuss UM decisions
• Policy on denial notices and the appeals notification process 

UM Medical Necessity Criteria, including how to obtain or view a copy

UM criteria and UM procedures and processes are available to L.A. Care practitioners, providers, members and their representatives, and the public upon request.  To obtain a copy of any L.A. Care UM criteria, UM procedure or UM process, practitioners, providers, members and their representatives, and the public may contact the L.A. Care Member Services Department at 1-888-839-9909 or the L.A. Care UM Department at 1-877-431-2273 and ask to speak with the UM Director or UM Manager to make the request. 

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Policy Prohibiting Financial Incentives for Utilization Management Decision-makers

Utilization management decisions are based only on appropriateness of care and service and the existence of coverage.  There are no rewards or incentives for practitioners or other individuals for issuing denials of coverage, service, or care.  There are no financial incentives for utilization management decision-makers to encourage decisions that would result in underutilization.

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How to Communicate with UM Staff and instructions for triaging inbound calls specific to UM cases/issues

L.A. Care Health Plan provides access to staff for members and practitioners seeking information regarding the Utilization Management process and the authorization of care.

• UM staff is available during normal business hours Monday through Friday, 8:00 a.m. – 5:00 p.m.  After hours staff is available for urgent requests and assistance to members and practitioners.
• Members and practitioners may use the toll-free number to communicate with UM staff.  The toll free number is (877) 431-2273.
• Collect calls regarding UM issues are accepted.

Additional instructions on how to obtain authorizations and communicate with UM staff are listed in your L.A. Care Provider Manual.

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Availability of, and the process for, contacting a peer reviewer to discuss UM decisions

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Policy on denial notices and the appeals notification process

A requesting practitioner may call L.A. Care to discuss a denial, deferral, modification, or termination decision with the physician (or peer) reviewer, or may write to supply additional information for the physician (or peer) reviewer.

To file a reconsideration of a UM determination, it must be requested within 24 hours of the notice of action.

If a requesting practitioner would like to discuss this decision with the physician (or peer) reviewer, please call L.A. Care’s UM Department at 1-877-431-2273.

• L.A. Care’s UM Department responds to reconsideration requests within one (1) business day of the receipt of the requesting practitioner telephone call or written request.
• If the physician (or peer) reviewer reverses the original UM determination based on the discussion with, or additional information provided by the requesting practitioner, the case will be closed.
• If reconsideration does not resolve a difference of opinion, and the previous UM determination remains or a modification results, or if the requesting practitioner does not request reconsideration, the requesting practitioner may submit a request for review through the appropriate practitioner dispute processes or may appeal on behalf of the member, if appropriate.

Practitioner Appeal Processes--How to Dispute an Adverse Determination Process for Filing a Formal Appeal

If a requesting practitioner believes that the determination is not correct, he/she has the right to appeal the decision on behalf of the member by filing a grievance with L.A. Care Health Plan.  The requesting practitioner should submit a copy of the member’s denial notice and a brief explanation of his/her concern with any other relevant information to the address below:

L.A. Care Health Plan

Member Services Grievances/Appeals

555 West Fifth Street 29^th Floor

Los Angeles, CA 90013