Network Medical Management’s procedures for reviewing the appropriateness of care are aimed at promoting quality of care and efficiency within the health care delivery process. We recognize the need for concern about the potential for under-utilization and appropriately review, which includes, but is not limited to bed day reports, lengths of stay reports, pharmacy usage reports, and data on member concerns regarding access to services.
As a matter of policy, associates who make utilization management coverage decisions for Network Medical Management may not be compensated or given other incentives to make denial decisions. Utilization decision-making is based only on the appropriateness of care and services.
Quality Management Program, Policies, and Procedures are available upon request to members and providers by calling our Customer Service department at (877) 282-8272 Opt. 1, Monday-Friday between 9:00 AM to 5:00 PM PT.
Procedures and Criteria are disseminated to members and providers upon request by calling our Customer Service department at (877) 282-8272 Opt. 1, Monday through Friday between 9:00 AM to 5:00 PM PT. For the hearing impaired, please call our TTY telephone at 877-735-2929, Monday through Friday between the hours of 8:30 AM to 5:00 PM PT.
A requesting practitioner may call Network Medical Management to discuss a denial, deferral, modification, or termination decision with the physician (or peer) reviewer at (877) 282-8272 ext. 6195; Monday through Friday between the hours of 9:30 AM to 2:30 PM PT. All calls will be returned within 24 hours.