The function of Medical Authorizations is to ensure that medically
necessary services are rendered to our members at the most
appropriate level of care in a timely, effective and efficient
manner through a system that provides control of and accountability
for service utilization.
A
"Medically Necessary Service" is defined as a service
that is reasonable and necessary to protect life, to prevent
illness or significant disability, or to alleviate severe
pain through the diagnosis and treatment of disease, illness
or injury.
The
Utilization Management (UM) Committee oversees the medical
authorization function, continually reviewing UM data, physician/vendor
and member patterns, along with other utilization issues to
recommend changes for improvement to the UM program.
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The
Healthy Generations, Networks 1, 5 & 6
Authorization Grid is to be utilized by physicians
who are independently contracted with SCFHP. The Authorization
Grid outlines the medical authorization process for requesting
and providing medical services for Healthy Generations, Networks 1, 5 & 6 members. For
any questions regarding information or use of the Password
Protected Authorization Grid contact the SCFHP
Utilization Management Department at (408) 376-2000 and select
option #6, for assistance. |
