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.
Palo Alto Medical Foundation
Managed Care Department
PO Box 50549
Palo Alto, CA 94303
Phone: (650) 812-3700