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HMO Authorization and Referrals

The UC San Diego Health Managed Care team oversees eligibility, pre-authorization, referrals and claims about HMO coverage and can answer questions such as:

  • What your insurance covers
  • Status of your authorization
  • Billing and reimbursement

HMO Plans Served by Managed Care Team

We serve patients of these HMOs who receive primary care at UC San Diego Health:

Commercial HMO Plans

Medicare Advantage HMO Plans 

Policies

The Managed Care team applies these policies when making decisions about insurance eligibility, authorization, referrals and claims:

  • Our utlization management department reviews requests for medical necessity and adherence with contractual agreements. This process is based only on appropriateness of care and service and existence of coverage.
  • We do not reward practitioners or others for issuing denials of coverage or service care.
  • Financial incentives do not encourage decisions that result in under-utilization.
  • UC San Diego Health does not sub-delegate any decision making to any other entity
  • The utilization management department consists of administrative data entry coordinators with extensive coding and clinic experience, registered nurses, and a board-certified medical director who oversees all medical decision-making. We sometimes use the expertise of our medical specialists to assist in making determinations.
  • All decisions are communicated to the requesting provider via EPIC, and member notification of decisions are sent via MyUCSDChart or mailed to the patient.

Utilization management criteria are available to the member, practitioner and public.  Please contact us to receive a copy.

Utilization Management Medical Team

Associate Medical Directors: Allyson Kreshak, MD, Elizabeth Rosenblum, MD

Confidentiality

Social Security numbers may be used for internal verification or administrative purposes, as long as the use does not result in the public display or disclosure of the number in violation of requirements. The law does not prohibit providers/practitioners from billing with the SSN.  UC San Diego Health has privacy policies in place that address the following:

  • No person or entity will engage in the following:  [CA Civil Code 1798.85] Publicly posting or displaying an individual’s SSN in any manner 
  • Require an individual to use their SSN to access the Internet website unless a password or unique personal identification number or other authentication device is also required 
  • Require an individual to transmit their SSN over the internet Web site unless the connection is secure or the SSN is encrypted 
  • Print an individual’s SSN on any materials that are mailed to the member unless state or federal law requires the inclusion of the SSN on the document to be mailed

 

Contact Us

For Patients
619-471-9123
Monday – Friday: 8 a.m. to 5 p.m.
HealthNet Blue & Gold Members:
1-800-539-4072

For Providers
619-471-9123
Claims: Option 1
Specialty referrals: Option 2
General questions: Option 3

Mailing address:
200 West Arbor Drive, #8501
San Diego, CA 92103-8501

Claims submission address:
UC San Diego Managed Care
ATTN: Claims Department
PO Box 33728
San Diego, CA 92163-8501