Utilization management

Utilization management decision making is based only on the appropriateness of care and service and the existence of coverage. Sharp Rees-Stealy does not specifically reward practitioners or other individuals for issuing denials of coverage or service care. Sharp Rees-Stealy does not offer financial incentives to utilization management decision makers that encourage decisions that result in underutilization. Practitioners are ensured independence and impartiality in making referral decisions that will not influence hiring, compensation, termination, promotion or any other similar matters.

• Sharp Rees-Stealy's Utilization Management Department is responsible for determining what health care services are covered and payable under the health plan

• These determinations are based on criteria that assess clinical information and individual circumstances, which include durable medical equipment, hospital admissions, home health care services and skilled-nursing facility admissions

You may obtain a copy of the actual benefit provision, guideline, protocol or other similar criterion on which the decision was based, upon request and free of charge.

Access to clinical criteria for referral authorization decisions

We use a standardized hierarchy of clinical guidelines when making referral authorization decisions. The exact criteria used will always be listed in the authorization notification sent to both members and providers.

Requests are reviewed using the following required order:

1. Federal/state mandated guidelines: Medicare NCDs and LCDs are publicly available through the Medicare Coverage Database.

2. Health plan guidelines: If the member’s health plan publishes its own guidelines, those must be used. Members should contact their health plan’s Member Services. Providers may refer to the health plan’s provider portal.

3. MCG clinical guidelines: Used when mandated or health plan criteria do not apply.

4. Sharp Rees-Stealy Medical group policies: Used only when higher-level criteria do not apply.

The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual needs and the benefits covered under your contract.

Sharp Rees-Stealy Medical Group policies

• Department Guideline 0002 – Out of Network Requests

• Medical Necessity, 01524.99

• Authorization and Denial of Reimbursement to Out of Network Providers for Post-Stabilization Care, 01971

• Department Guideline 0051 – Medication Selection

• National Comprehensive Cancer Network (NCCN) guidelines

• FDA Purple Book

Contact us about utilization management

Members and providers can contact Utilization Management for assistance in understanding any guidelines used. Staff are available from 8 am to 4:15 pm on normal business days to receive inbound, collect or toll-free calls.

• Sharp Rees-Stealy Utilization Management: 858-499-2532 or toll free at 1-800-82-SHARP (1-800-827-4277 )

• After-hours/weekends: 1-800-377-4277

• TTY/TDD: 858-499-4645

Language assistance is available for members to discuss utilization management issues.