Utilization Management

Department objectives include establishment/implementation of written UM protocols and criteria applicable to medical necessity review, provision of alternative suggestions of treatment to the practitioner, concurrent review of all in-patient hospitalizations, discharge planning, evaluation of practice patterns along with identification of care variation, and assuring that regulatory turnaround time frames are met or exceeded.

We are proud of our transitions of care program which ensures that patients have a follow-up appointment scheduled with their provider after discharge. Central to our review process is the availability of board-certified physician reviewers in key specialty areas. Medical directors are available for peer-to-peer reviews with the patients’ providers.

Providers are encouraged to use MedPOINT’s web portal to request authorizations and look up status information. Once the authorization is completed, a print screen is available for posting in patient charts. Specialist notes and other pertinent information is also attached to the web profile. Additionally, MedPOINT is currently exploring ways to automate receipt of referral requests.

MedPOINT, on behalf of its contracted IPAs, will make available to its members and practitioners, upon request, verbally or in writing, information about its Utilization Management Program, including a description of the Quality Management Program/Plan and a report of progression toward meeting its goals. Members and Practitioners may obtain copies of criteria used to make Utilization Review decisions by calling 818.702.0100. The Medical Directors and other UM personnel are also available to accept collect calls from callers who have questions about the UM process by calling 818.702.0100.