Managed Care Ensures Appropriate Utilization Management Service and Coverage

In accordance with National Committee on Quality Assurance (NCQA) standards:

• Palo Alto Medical Foundation (PAMF) employees and Palo Alto Foundation Medical Group (PAFMG) 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.
  
• PAFMG 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.

Managed Care staff will accept collect calls regarding UM issues during normal business hours (8 a.m. – 4 p.m.). AT&T TDD/TTY Services for the deaf are also offered. Members, practitioners or the public should direct all requests either in writing or by telephone to Managed Care at the contact information below:

Palo Alto Medical Foundation
Managed Care Department
2350 West El Camino Real
Mountain View, CA 9494040
Phone: 650-934-8677