Utilization Management

Nivano Physicians offers Authorization/Utilization Management services delivered by health care professionals. Our professionals are trained in the health plan’s policies and procedures as well as applicable regulatory agency requirements.

These guidelines are applied when a prior authorization for a physician service is needed. Determination of authorization is based on review and evaluation of information submitted from the requesting physician and/or obtained from review of existing medical records. Specific care and treatment authorization may vary depending on individual need and benefits covered under the individual’s plan. These criteria are available on request for specific treatment. The Utilization Management department can be reached Monday through Friday from 8 am to 5 pm PST at (916) 407-2000 or our toll free line (844) 889-2273. Then, press 2 for Authorizations.

The use of incentives for its utilization management programs or coverage determinations is specifically prohibited under Nivano Physicians contracts. Bonuses or incentive pay may not be used in any way to influence a practitioner’s decision to withhold, delay or deny necessary medical services. Any financial incentives used for utilization management are not linked or used to encourage decisions that result in under-utilization.

Nivano Physicians Medical Group has processes in place to provide access to staff for members and practitioners seeking information about the Utilization Management (UM) process and the authorization of care. Utilization Management Member Services staff are available at least eight (8) hours a day during normal business hours (8:00 AM – 5:00 PM Monday through Friday) to receive inbound communication regarding UM issues. They can be reached at 1-844-889-2273. Member services staff are authorized to accept collect calls from members regarding UM issues. The UM Department has a voice mailbox to accept after hour messages. Calls are returned the following business day during the week. Weekend messages are returned on Monday morning.

UM Prior Authorization Form

SAR Form

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