Central California Alliance For Health


Utilization Management Guidelines

The Alliance Utilization Management (UM) program implements a comprehensive, integrated process that actively evaluates and manages the utilization of health care resources delivered to our members, and actively pursues identified opportunities for improvement. The UM program ensures that:

• Members receive the appropriate quantity and quality of health care services

• Service is delivered at the appropriate time

The Alliance utilization process provides a system that verifies equitable access to appropriate, cost-effective health care resources for all members. For authorization purposes, a requested service or medical equipment is approved if it is a covered benefit and is determined to be medically necessary.

The UM program provides a reliable mechanism to review, monitor, evaluate and address utilization-related concerns as well as recommend and implement interventions to improve appropriate utilization and resource allocation.

In order to achieve appropriate and standardized decisions, the UM program processes requests using a systematic, consistent application of utilization management criteria. Clinical care decisions are determined by the Alliance's qualified, experienced UM team using evidence based guidelines developed and approved by the Alliance's Utilization Management Committee (UMC). For medical necessity determinations, the Alliance utilizes evidence-based medical necessity criteria in a decision hierarchy.

Decision Hierarchy

1.  Title 22 California Codes of Regulation Division 5 criteria

2.  Medi-Cal Medical Necessity Guidelines (when available)

3.  Alliance Health Services and Pharmacy guidelines, policies and procedures
     approved by the UMC

4.  Evidence-based guidelines, such as:
       a. MCG care guidelines
       b. Medicare (CMS) Guidelines

5.  Consensus statements and nationally recognized standards of practice
     (please click here for a list of resources)

6.  Guidelines developed by other health plans

7.  Expert opinion:
       a. Clinical advisors serving on Alliance committees
       b. Outside Independent Medical Review



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