UC San Diego Health Managed Care applies these policies when making decisions about insurance eligibility, authorization, referrals and claims.
The UC San Diego Health Plan Services Utilization Management Department reviews requests for medical necessity and adherence with contractual agreements. The utilization management decision-making process is based only on appropriateness of care and service.
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 elements 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
The UM decision making process is based only on appropriateness of care and services, and existence of coverage.
UC San Diego Health Managed Care does not reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service care.
Financial incentives for utilization management decision-making do not encourage decisions that result in under-utilization.
UC San Diego Health does not sub-delegate any decision making to any other entities.
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