Utilization management
Sharp Rees-Stealy’s Utilization Management Department is responsible for determining what health care services are covered and payable under the health plan.
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 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.
Health plan guidelines
Please refer to your health plan for specific guidelines or coverage details. For personalized guidance, visit your health plan’s website or contact the health plan’s customer service for assistance.
For Medicare Advantage, you can review the criteria used to base authorization decisions. If Medicare guidelines and your health plan do not have criteria for your specific need, Sharp Rees-Stealy Medical Group will use third-party guidelines or approved medical group policies for the purpose of basing the referral decision. The notification you receive will state the specific criteria utilized.
Sharp Rees-Stealy Medical Group policies
Contact us about utilization management
You may refer your questions or requests to the Utilization Management Department by calling 858-499-2600 or 1-800-377-4277.
Language assistance is available for members to discuss utilization management issues.