Utilization Management

Authorization of Services

All new Western Health Advantage (WHA) members must choose or be assigned to a Primary Care Physician (PCP). The PCP provides direct care and treatment, monitors patients' health status, and makes referrals to specialty providers when needed. All non-urgent or non-emergency care and services should be provided by the member's assigned PCP or from another WHA participating (network) provider when appropriate.

Primary Care Physicians and specialists belong to an independent practice association (IPA) or medical group (group) which contracts with WHA to provide health care services to our members. Certain services a doctor recommends may require prior authorization (pre-approval) from the PCP's affiliated group or from WHA at the health plan level to ensure coverage. Other services, such as in-network annual eye exams and routine gynecological and obstetrical care, do not require authorization as long as a network professional provides the service. The PCP should know when authorization is needed or not per his/her group's specific policies and practices.

When a patient needs specialty care and a referral or authorization is required, the PCP should submit a request to his/her affiliated group for review, tracking or decision-making. Experienced clinical professionals (review doctors and nurses) evaluate requests for benefit coverage and services to determine medical necessity using established criteria. Notification of the decision is made electronically, by phone or Fax to the requesting provider then followed in writing to the PCP, member and named provider of the service. Timeframes for processing requests, making decisions and issuing decision notices are all mandated through state regulations to ensure timeliness.

If a request is denied or modified by a physician reviewer and the member and/or physician disagrees, the member or a representative acting on his/her behalf, including the physician, may file an appeal with WHA. During the appeal process, a different healthcare professional from the one that made the initial decision must conduct the review. If the member, representative or provider is dissatisfied with WHA's appeal decision, state regulations may allow an external organization to evaluate the individual case and make an independent decision, which is binding on the health plan. This independent review process is handled through the California State Department of Managed Health Care (DMHC), which is responsible for HMO licensure. The department has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online

For other details on Utilization Management processes, see the Frequently Asked Questions (FAQs) selection available on this website.