Clinical Criteria for UM Decisions
Serra’ s UM Department uses criteria or guidelines to make decisions based on medical necessity. These guidelines are developed through technology assessment and structured evidence reviews, evidence -based consensus statements, expert opinions of healthcare providers, and evidence-based guidelines from nationally recognized professional healthcare organizations and public agencies. The guidelines come from a variety of sources which include:
- Center for Medicare and Medicaid Services (CMS)
- National Coverage Determinations
- Local Coverage Determinations
- CMS Benefit Interpretation Manuals
- Medi-Cal Coverage Guidelines
- Apollo Medical Review Criteria
- Evidence in the peer-reviewed published medical literature
- Health Plan Medical Policies
Availability of Criteria
Providers and members have the right to request a copy of a guideline that Serra has used to make a treatment authorization request decision. Specific criteria or guideline are also available to the public upon request with the following disclosure: “The material provided to you are guidelines used by the Per plan to authorize, modify, or deny care for the person with similar illnesses or conditions. Care and treatment may vary depending on individual need and the benefits covered under you contract.” If you would like to obtain a copy of a particular criteria, please contact the Serra UM Department at 818-504-4569.
SMG shall provide detailed information regarding denials and the denial process. The Denial letter contains important information specific to the member’s health plan and process. Below is a list of some of the information more information can be found in the Denial Policy.
- The action taken, the reason for the action taken and a citation of the specific UM criteria, regulations or plan authorization procedures supporting the action.
- Members may contact their provider to obtain explanation or detail of diagnosis or treatment codes and their meanings.
- Member’s right to, and method of obtaining, a fair hearing to contest the decision.
- Notice that the member may use the health plan Complaint/Grievance process prior to or concurrent with the initiation of the state fair hearing process.
- Health Plans Complaint/Grievance information, including the address and telephone number.
- State Fair Hearing information – Patient’s right to, and method of obtaining, a fair hearing to contest the decision and the time limit for requesting a fair hearing.
- The member has the right to request continuation of benefits during an appeal or State Fair Hearing.
- Health Plans Grievance/Complaints address and telephone number.
- Information re: Department of Managed Health Care (DMHC) information (with TTY and web address) Complaint Process.
- The member’s right to obtain an independent Review (IMR) through the Department of Managed Health Care (DMHC).
- The State’s toll-free telephone number for obtaining information on legal service organizations for representation.
Affirmative Statement About Incentives
UM Decisions are based appropriateness of care, service, and existence of coverage. Serra does not specifically reward practitioners or individuals for issuing denials of coverage or care. Financial incentives for UM decision makers do not encourage decisions that result in under-utilization. Provider and practitioners are not prohibited from acting on behalf of the member. Physicians cannot be penalized in any manner for requesting or authorizing appropriate medical care. Practitioners are ensured independence and impartiality in making referral decisions that will not influence:
- Any other similar matters
Availability of Physician Reviewer
Only licensed physicians can make a denial decision. The physician reviewer is available to discuss denial decisions with the requesting practitioner and can be reached by calling 818-504-4750.
Licensed physicians oversee all UM Decision making process. Appropriate licensed health professional conducts the supervision of all review decisions and process. All denied or modified requests are determined only by qualified physicians. Non-Licensed staff members may collect data for pre-authorization and concurrent review under the supervision of a licensed personnel.
Access to UM Department Staff
- Serra provides the following communication services for member and practitioners:
- Staff is available at lease eight hours a day during normal business hours for inbound collect or toll-free calls regarding UM issues
- Staff can receive in bound communication regarding UM issues after normal business hours.
- Staff is identified by name, title and organization name when initiating or returning call regarding UM issues
- TDD/TTY service (711) is available to members who have hearing or speech impairment.
- Language assistance is available to members to discuss UM issues.
Nurse Advice Line/ Afterhours Services Line
Health Plans have a 24 hour, 7 days a week Nurse Advice Line available by calling the toll-free number listed on the back of members insurance card. Serra members can also access our After-Hours Service Line to receive fast and free medical advice over the phone by the on-call physician that is available 24 hours a day, 7 days a week, including weekends and holidays. Members can call 818-768-3000.
UM Timeliness Standards
Timeliness standards for decision-making and notification of decisions for all lines of business.
- Emergency post-stabilization services decision-within 30 minutes of verbal requested
- Urgent (expedited) requests-decision within 72 hours; initial provider notification within 24 hours; written member and provider notification within 72 hours from initial receipt of the request, including weekends and holidays.
- Pre-Service routine (non-urgent) requests-decision within 5 working days; initial notification to practitioner within 24 hours of the decision, written notification to member and practitioner within 2 business days of making the decision.
- Decision and written notification to the member and provider for deferred or delayed requests shall not exceed 14 calendar days.
- Retrospective review decision-within 30 days.
- Hospice inpatient care-24-hour response.
- Expedited Review decision-within 72 hours.
- Standard-decision within 14 calendar days; member notification shall be done as expeditiously as the member’s condition requires, but not later than 14 calendar days after receipt of request.
- Expedited- decision within 72 hours; notification within 72 hours after receipt of request.
- Extension (if justified)-additional 14 calendar days.
- Termination of Services-no later than 2 calendar days of 2 visits before the coverage ends.
- Urgent-decision not to exceed 72 hours after receipt of request; notification within 72 hours of receipt of request.
- Decisions- member and practitioner notification for urgent request shall be done within 24 hours of the receipt of request.
- Urgent Concurrent-decisions within 24 hours of receipt of request; notification within 24 hours of receipt of request.
- Non-Urgent-decisions within 5 business days; initial notification to practitioner within 24 hours of the decision, written notification to member and practitioner within 2 business days of making the decision.
- Standing-decision within 3 business days of receipt of request; notification time frame depends on the service category.
Initial Health Assessment (IHA)
All Medi-Cal members should receive timely access to an IHA within 120 days of enrollment regardless of age. Additionally, if a member refuses an IHA, the refusal must be documented in the medical record.
A provider of medical services may submit a grievance concerning an authorization or denial of a service, denial, deferral, or modification of a prior authorization request or claim by calling Serra Medical Group UM Department at (818) 504-4569 or the Claims Department at (818) 504-4681.
Providers who are submitting claims for retroactive review (review after the services have been provided) should submit the claims directly to SMG UM Department. If the UM Department requested that you send medical records, please submit your response to the UM department.
If a provider would like to appeal or dispute a claim payment, the provider must submit it in writing by mail to SMG Claims Department. All appeals and disputes are entered in the SMG Database for investigation, and providers will receive a written response.