Utilization Management Services
Sutter Health Sutter Valley Medical Foundation's Continuum Case Management provides utilization management services for Health Maintenance Organizations (HMO) health plans contracted with Sutter Independent Physicians and Sutter Medical Group and Sutter Gould Medical Group.
Sutter’s utilization management services are designed to monitor, evaluate, and manage the cost and quality of health care services delivered to all patients of Sutter Independent Physicians and Sutter Medical Group. Sutter utilization management performs prospective, concurrent, and retrospective review of services requested by health care providers using nationally accepted criteria and informational resources to determine the appropriateness of healthcare services.
All practitioners, providers, and utilization management staff involved in decision making processes are required to sign affirmation statements regarding confidentiality and incentives. The statement acknowledges the following for utilization management decision makers:
- Utilization management decision-making is based only on appropriateness of care and service and existence of coverage.
- The utilization management organization does not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service care.
- Financial incentives for utilization management decision makers do not encourage decisions that result in under utilization.
- Reviewers are ensured independence and impartiality in making referral decision
that do not influence:
- Hiring
- Compensation
- Termination
- Promotion
- Any other similar matters
Sutter Case Management undergoes annual HMO Utilization Management oversight audits to ensure compliance with state and federal regulatory requirements.
Practitioners, providers, members, or member's representatives can contact Sutter Case Management staff Monday through Friday from 8:00 am to 5:00 pm at (916) 649-4100 or toll free through customer service at (888) 516-8023 to inquire about utilization management processes, affirmative statements, or criteria/guidelines. For assistive listening systems, Sacramento Division, call NorCal Center for Deafness at (916) 349-7500; for Relay Service, Sacramento Division, call 711; for Speech to Speech, Sacramento Division, call 711 and ask for Speech to Speech.