Utilization Management
Golden Coast MSO has a Utilization Management program to ensure that members have access to quality health care. The program utilizes a team of health care professionals to evaluate the medical necessity of the services by using nationally recognized, evidence-based clinical guidelines and community standards. The decisions are based on the appropriateness of care and services available to members within their contracted benefits. Golden Coast MSO affirms the following Utilization Management program practices:
Utilization Management decision-making is based only on the appropriateness of the care and services requested, the existing coverage and benefits available
Utilization Management staff are not rewarded or otherwise incentivized to issue denials of coverage of services
Utilization Management decision-making staff members do not receive financial incentives that encourage decisions resulting in underutilization
As a reminder to all associated practitioners, providers, enrollees and employees that make UM decisions, the following statement is being distributed as required by our contracted plans: Utilization Management decision making is based only on the appropriateness of care and service. Golden Coast MSO does not specifically award or compensate practitioners or other individuals conducting utilization review for issuing denials of care. Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization. All practitioners are ensured independence and impartiality in making referral decisions that will not influence hiring, compensation, termination, promotion, or any similar matters.
Clinical Issues Are Reviewed and Determined by Doctors
Affirmative Statement
Golden Coast MSO, on behalf of its contracted IPAs and hospital groups, affirms that it encourages appropriate utilization of medically necessary member care and discourages under-utilization of services by the following statements:
UM decision making is based only on appropriateness of care and services and existence of coverage
Golden Coast MSO does not specifically reward practitioners or other individuals for issuing denials of coverage or service care
Financial incentives for UM decision makers do not encourage decisions that result in under-utilization
Providers and practitioners are not prohibited from acting on behalf of the member
Physicians cannot be penalized in any manner for requesting or authorizing appropriate medical care
Practitioners are ensured independence and impartiality in making referral decisions that will not influence: hiring, compensation, termination, promotion or any similar matters
Member Services Department Contact Information:
To discuss a denial, request an appeal, or obtain a copy of the criteria used, please call our Member Services Department.
Call: 909-461-1515
Hours of Operation: Monday – Friday; 9 a.m. – 5 p.m.
Criteria used for a specific review decision is made available to providers, members and the public upon request to the Golden Coast MSO Member Services Department.