Sutter Gould Medical Foundation's Utilization Management Program
Sutter Gould Medical Foundation's Utilization Management (UM) program is designed to ensure that managed care members receive timely, medically necessary, and cost-effective care services.
Services that we provide to our patients as part of the program:
- Prior authorization/concurrent review
- Discharge planning
- Case Management
- Retrospective review
Our UM staff, including RNs and trained representatives, work closely with our medical staff to help coordinate with external specialists. Our goal is to meet the needs of our patients as well as the program.
The managed care plans include Health Net, United Health Care, Secure Horizons, Blue Shield, Blue Cross, California Care, Cigna, Aetna, Humana and Sutter Health Plus.
Utilization Management Policies and Procedures
Sutter Gould Medical Foundation uses approved guidelines from the health plans medical management policies and MCG Health, LLC (formerly Milliman Care Guidelines) criteria (approved by the health plans) to review referral requests submitted by contracted providers and primary care physicians. These guidelines are reviewed and updated by these organizations periodically to remain current with new treatment and trends. The criteria provide a guideline only to approve, modify or deny care for persons with similar conditions. Specific care and treatment may vary depending on individual need a benefit covered under the individual’s plan. The criteria are available on request for a specific treatment.
Sutter Gould Medical Foundation ensures that decisions are made only on appropriateness of care, service and existence of coverage. Sutter Gould Medical Foundation managed care staff or providers do not receive any compensation, direct or indirect or financial incentives based on review decisions. Providers are ensured independence and impartiality in making referral decisions that will not influence hiring, compensation, termination, promotion, or any other similar matters.
Sutter Gould Medical Foundation encourages appropriate utilization and discourages inappropriate under-utilization by providers and staff.
Any questions regarding this notice may be directed to Sutter Gould Medical Foundation's Utilization Management Department at (209) 550-4712, Monday through Friday from 8 a.m. to 5 p.m. Collect calls will be accepted from out of area callers.