MLMSO’s Utilization Management program is designed to ensure the delivery of medically necessary, quality patient care through appropriate utilization of resources in a cost effective and timely manner including inpatient, outpatient, and the emergency room. Services are coordinated with our client’s Medical Director and MLMSO’s utilization management team to ensure all levels of care are achieved and/or surpassed, and programs are consistently and systematically monitored and evaluated to assure that authorized services are consistent with the benefits provided by the Plan. Nationally accepted criteria, guidelines, standards, criteria set by governmental and other regulatory agencies are adhered to and utilized in determining medical necessity and appropriateness. Continuous monitoring and communication with our contracted health care providers allow us to follow the patient throughout the healthcare delivery system and assure that appropriate settings and resources are utilized. Reports are generated daily to provide meaningful interpretation of data regarding analysis of utilization, savings, and the impact of benefits design.
AFFIRMATIVE STATEMENT REGARDING UTILIZATION-RELATED INCENTIVES:
Utilization Management (UM) decision making is based solely on medical necessity, appropriateness of care and service, and existence of coverage, and that MedLogix Management Services Organization (MLMSO), on behalf of its contracted IPAs does not specifically compensate practitioners or individuals conducting utilization review for issuing denials, nor MLMSO offer incentives to encourage decisions that result in underutilization or denials.
Practitioners are ensured independence and impartiality in making referral decisions that will not influence the following: hiring, compensations, terminations, promotions, and/or any other similar matters.
REQUEST FOR CRITERIA USED:
Members and providers may obtain copies of criteria used to make Utilization Review decisions by verbal or written requests.
CONTACT INFORMATION:
Our Utilization Management staff is available during normal business hours (8:30AM to 5:30PM PST Monday through Friday) to answer any questions regarding the UM process. To speak to a UM staff member, please call (657) 217-4500.