The purpose of the Utilization Management program is to assure the delivery of medically necessary quality patient care through appropriate utilization of resources in a cost-effective, timely manner for all members. Standard criteria and informational resources are utilized to determine the appropriateness of healthcare services. The review process takes into consideration the individual needs of the member such as age, co-morbidities, complications, progress of treatment, psychosocial situation, and home environment.

Prior authorizations of proposed services, referrals or hospitalizations involve verifying the member’s eligibility and benefits. The requests for authorization should include written documentation by the physician of medical necessity for the service or procedure. The clinical documentation is assessed for medical necessity, appropriateness of level of care, and the availability of services within the network. Referrals to out of network providers should include documentation of the rationale for the requested out of network services.

Providers may request policies, procedure, and criteria used to authorize, modify, or deny healthcare by calling Riverside Physician Network’s Medical Management Department at 951-788-9800. Or click link for our online Manual.

Each denial written details the procedure for the requesting provider to contact the physician reviewer to discuss the UM denial decision. This information includes the reviewer name and phone number.