Utilization Management Ensures Appropriate Service and Coverage for HMO Members
In accordance with National Committee on Quality Assurance (NCQA) standards:
- Palo Alto Medical Foundation (PAMF) employees and Palo Alto Foundation Medical Group (PAFMG), and Mills-Peninsula Medical Group (MPMG) physicians who make utilization related decisions, and those who supervise them, ensure decisions are based only on appropriateness of care and service. Economic profiling is not used.
- PAMF does not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service or encourage decisions that result in underutilization.
- Compensation plans for individuals who provide utilization review services do not contain direct or indirect incentives, financial or other, for these individuals to make inappropriate review decisions.
- Members have the right to independent, external review of final determinations.
- Members or their legal guardians may designate, in writing, a representative to act on their behalf.
- Members, practitioners, and the public have the right to request clinical criteria, including requests for emerging and current technologies, devices, medical procedures and techniques, or to discuss denial decisions and/or UM issues with appropriate practitioners.
- AT&T TDD/TTY services for the deaf are available by dialing 711 or through the California Relay by calling 1-866-660-4288.
Members, practitioners or the public should direct all requests either in writing or by telephone to Utilization Management at the contact information below:
Palo Alto Medical Foundation
Utilization Management (UM) Department
PAFMG Division - Centers in the East Bay, Santa Cruz, the San Carlos Center down to San Jose and Los Gatos
PO Box 50549
Palo Alto, CA 94303
Hours: 8 a.m. to 5 p.m.
Mills-Peninsula Division - Centers in Daly Center, Burlingame, San Mateo
PO Box 4348
Burlingame, CA 94011-4348
Phone: (650) 240-8052
Toll free number: (855) 729-2052
Hours: 8:30 a.m. to 5 p.m.
Below are hotlines for participating Health Plans at PAMF for filing a grievance.
Anthem Blue Cross
Blue Shield of California
Cigna Health Plan
TTY/TDD: ext. 711
Sutter Health Plus