The department is comprised of three main areas: inpatient review, outpatient review, and case management department The utilization management program is designed to monitor, evaluate and manage healthcare services delivered to contracted IPA members. The program provides for fair and consistent evaluation of medical necessity and appropriateness of care through use of nationally accepted and internally developed clinical practice guidelines. The department works to ensure consistent delivery of the highest quality health care and optimum member outcomes. The program activities are developed and implemented in compliance with state and federal regulations, as well as the requirements of the health plans. A formal evaluation of the Quality Management Program is performed annually.Department objectives include establishment/implementation of written UM protocols and criteria applicable to medical necessity review, tracking quality issues referred from UM, providing alternative suggestions of treatment to the practitioner when a service is denied based on the medical information submitted, 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.Providers are encouraged to use Pacific Health MSO web portal to request authorizations and look up other information. Once the authorization is completed, a print screen is available for posting in patient charts. Network providers are included in the utilization management and quality management process through committee participation, which are functional components of the program.
