UTILIZATION MANAGEMENT
CCMSO’s Utilization Management department consists of inpatient, outpatient and case management department.  CCMSO’s Utilization Management is designed to evaluate and monitor the health care services delivered to contracted IPA members.  The program provides for fair, cost effective and consistent evaluations of medical necessity and appropriateness of care in a timely manner through the use of regulatory guidelines and governmental approved criteria. The department works to ensure consistent delivery of the highest quality health care for the best possible member outcomes. The program activities are developed and implemented in compliance with state and federal regulations, as well as the requirements of the health plans.

REQUEST FOR CRITERIA USED:

Members and providers may obtain copies of criteria used to make Utilization Review decisions by verbal or written requests.

AFFIRMATIVE STATEMENT REGARDING UTILIZATION-RELATED INCENTIVES:

In accordance with National Committee on Quality Assurance (NCQA) standards, UM staff of Crystal Coast Management Services Organization (CCMSO) and the Medical Directors who make or supervise utilization related decisions base these decisions only on the clinical appropriateness of care and service. CCMSO does not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service. In addition, there are no financial incentives for Utilization Management decision makers, and CCMSO and its contracted IPAs do not encourage decisions that result in underutilization.

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 (714) 495-2111.