The Sutter East Bay Medical Foundation utilization management (UM) program is designed to ensure that managed care (HMO) members receive timely, medically necessary, and cost-effective healthcare services. We provide the following to our patients as part of this program:
- Prior authorization/concurrent review
- Discharge planning
- Care management
Our UM staff, including RNs, LVNs, and trained representatives work closely with
our medical staff to help coordinate care by outside specialists. Our goal is to meet
the needs of our patients and the program.
The managed care plans with which Sutter East Bay Medical Foundation is contracted include: Aetna, Anthem Blue Cross, Blue Shield, Health Net, Health Net Seniority Plus, PacifiCare/United HealthCare, and Secure Horizons.
Utilization Management Policies and Procedures
- Guidelines – Sutter East Bay Medical Foundation uses approved guidelines from health plans’ medical management policies and Milliman criteria (approved by the health plans) to review authorization requests submitted by contracted providers and primary care physicians. These guidelines are reviewed and update by the organizations periodically to remain current with new treatments and trends. The criteria provide a guideline only to approve, modify or deny care for persons with similar conditions. Specific care and treatment many vary depending on individual needs and covered benefits. The criteria are available upon request for a specific treatment.
- Decision Making – Sutter East Bay Medical Foundation ensures that decisions are made only on appropriateness of care, service and existence of coverage. UM staff and providers do not receive any direct or indirect compensation or financial incentive based on review decisions.
- Sutter East Bay Medical Foundation encourages appropriate utilization and discourages inappropriate under-utilization by providers and staff.
Please contact our customer service department at (866)
681-0745 from 8:00 am to 5:00 pm for questions regarding referrals, authorizations
or billing questions. Specific questions regarding the utilization management process
can be directed to (866) 681-0745.
For hearing impaired members, please contact California Relay Services by calling 711, or call their toll free number at (800) 855-7100, or their Spanish speaking dedicated number (800) 855-7200.