Utilization Management Program

Heritage Sierra Medical Group (HSMG) composes an annual Utilization Management (UM) Program. The UM Program specifies the programs goals, objectives, scope, and organization structure as well as performance standards.

The Utilization Management Committee will monitor and evaluate medical care and services throughout the organization to increase cost-effectiveness. Medical Services, Inpatient Services, Clinical Compliance, Quality Management and contracted Behavioral Health Providers all play an equally important role in accomplishing this goal. Each department at HSMG is responsible for meeting set performance standards, reviewing processes and procedures, to ensure we provide excellent service to our members and providers.

Opportunity to Discuss with a Reviewer

For denials resulting from medical necessity review, providers will be given the opportunity to discuss denial decisions with a physician or other appropriate reviewer. This opportunity may be provided, but does not guarantee a change in the decision and decisions cannot be changed after member notification has been sent:

• In the written denial notification, which includes the name and direct telephone number of the health care professional responsible for the denial or modification determination; or

• By telephone, which may include leaving a voicemail; or

• In other materials sent to the treating provider, informing the provider of the opportunity to discuss a specific denial with a reviewer.

For any questions regarding the HSMG Utilization Management decision-making or other issues related to the Utilization Management process, please call (661) 273-7346.

• HSMG Utilization Management Plan

• 2025 Clinical Practice & Preventative Health Guidelines Physician Quick Guide and Group Listing & Source

• DHCS Staying Healthy Assessment

• Affirmative Statement

Notices:

• DHCS Nondiscrimination Notice

• DHCS Language Assistance Taglines

Language Assistance/Interpreter Services:

In accordance with California Assembly Bill 853, all HSMG providers will provide, at no cost to the HSMG member, Language Assistance/Interpreter Services for those that are limited in English proficiency. Ask your physician for assistance if you need help with interpreter services.

HSMG offers TDD/TTY services for deaf, hard of hearing, and speech-impaired members. Please call (toll free): (800) 806-4474 .

Disclaimer:

Heritage Sierra Medical Group (HSMG) does not reward or offer incentives to employees or associates to encourage inappropriate under-utilization of services. Rather, HSMG is committed to providing quality care to our members, and therefore:

• Utilization Management decision making is based only on appropriateness of care and service and existence of coverage.

• HSMG does not specifically reward practitioners or other individuals for issuing denials of coverage or service care.

• Financial incentives for UM decision makers do not encourage decisions that result in under-utilization.