Utilization Management decision making is based only on the appropriateness of care and service and 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 refer questions to the Utilization Management department or 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, by calling 858-499-2406 or 1-800-377-4277. Language assistance is available for members to discuss utilization management issues.
To learn more about utilization management, please call your treating physician. Be sure to select a primary care doctor at Sharp Rees-Stealy when you choose your insurance plan. For help choosing a Sharp Rees-Stealy doctor who is right for you, call 1-800-82-SHARP (1-800-827-4277), Monday through Friday, 7 am to 7 pm, or search Sharp Rees-Stealy doctors.
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"I believe in patient-centered care and work with both the child and parent in developing a plan for optimal health."
"I enjoy connecting with patients and their families to provide open and caring communication."
"I strive to evaluate the global health of children and to avoid unnecessary medicines."
"I am honored to serve as President of Sharp Rees-Stealy Medical Group where my colleagues and I strive to provide excellent care and always put the patient first."