Utilization Management Department

The role of the Utilization Management (UM) Department is to ensure consistent delivery of appropriate and quality health care services to our members through Care1st affiliated providers. The UM functions include pre-certification, inpatient concurrent reviews, discharge planning, and retrospective reviews. Health care services are provided through a combination of direct contracts and full and shared risk networks structured to provide a continuum of care.

Care1st Health Plan makes Utilization Management (UM) decisions only on appropriateness of care and service, including existence of coverage. Care1st does not reward practitioners or other individuals for issuing denials of coverage or care. There are no financial incentives that would encourage UM decision makers to make decisions that would result in under-utilization of services.

The Criteria

The UM Department uses clinically sound, nationally developed and accepted criteria for making medical necessity decisions. Following is a listing of the clinical criteria used, but is not limited to:

  • Milliman Care Guidelines
  • American College of Obstetrics and Gynecology
  • The American Academy of Pediatrics
  • The United States Preventative Services Task Force Standards
  • L.A. Care Benefit Interpretation Manual
  • The Department of Health and Human Services Health Care Guidelines

(Care1st Health Plan uses nationally recognized clinical criteria in order to make UM decisions. These criteria are available to you upon request, by contacting the Care 1st Member Services Department toll-free at the following numbers:

MediCal
Los Angeles: 1-800-605-2556 (TTY/TTD 711)
San Diego: 1-855-699-5557 (TTY/TTD 711)
Medicare
1-800-544-0088 (TTY/TTD 711)

For any UM issues, Case Management and Complex Case Management related questions or referral information, please contact the Care 1st Member Services Department toll-free at the following numbers:

MediCal
Los Angeles: 1-800-605-2556 (TTY/TTD 711)
San Diego: 1-855-699-5557 (TTY/TTD 711)
Medicare
1-800-544-0088 (TTY/TTD 711)

Affirmative Statement and Utilization Management Criteria

  • Affirmative Statement
  • Utilization Management and Clinical Practice Guidelines