Utilization Management Providers

Utilization Management

Please see below for details on utilization management and clinical resources for your patients. If you need additional assistance, please Contact Us.

Prior Authorization

Certain health care services require Prior Authorization by the Medical Group or SHP in order to be covered. Primary Care Physicians must contact SHP or in some cases, the participating Medical Group with which a Primary Care Physician is affiliated, to request the service or supply be approved for coverage before it is rendered.

Certain Mental Health, Behavioral Health or Substance Use Disorder Treatment Services require Prior Authorization by Windstone in order to be covered. For Mental Health, Behavioral Health or Substance Use Disorder Treatment Services, the Windstone Participating Provider must contact Windstone for Prior Authorization. If Prior Authorization is not obtained when required, the member may be liable for the payment of services or supplies. Requests for Prior Authorization will be denied if the requested services are not Medically Necessary as determined by SHP or the Medical Group or Windstone, as applicable. Please contact SHP Member Services for additional information regarding services that require prior authorization.

Utilization Management Criteria

Seaside Health Plan adopts MCG (formerly Milliman Care Guidelines) including guidelines for:

  • Ambulatory Care
  • Home Care
  • Recovery Facility Care
  • General Recovery Care l Inpatient & Surgical Care l Chronic Care
  • Patient Information

Seaside Health Plan's recommendation of these guidelines is not an authorization, certification, explanation of benefits, or a contract. Benefits and eligibility are determined in accordance with the requirements set forth by the State of California

Drug Formulary

To view the prescription drug formulary, please visit the Prescription Drug List section under the For Providers page.

Mental Health

Your plan offers access to Mental Health, Behavioral Health Services, and Substance Use Disorder Treatment Services through Windstone Behavioral Health Inc. (a specialty Independent Practice Association). Treatment Services are coordinated and administered by Windstone. You do not need a referral from your PCP or from Windstone to see a Windstone Participating Provider for office visits for Mental Health, Behavioral Health Services, medication management or Substance Use Disorder treatment. Certain Mental Health, Behavioral Health and Substance Use Disorder services require prior authorization from Windstone

For Mental Health, Behavioral Health and Substance Use Disorder Services, call your Windstone provider at (800) 577-4701 (TTY users call (714) 384-3337), unless it is an emergency.

Visit http://www.windstonehealth.com/ for more information on Winstone Behavioral Health Inc. 

View a directory of Windstone Participating Provider:

PDF iconMemorialCare Medical Group Network.pdf

PDF iconGreater Newport Physicians Network.pdf

Chiropractic and Acupuncture

Access to chiropractic and acupuncture services is offered through American Specialty Health (ASH). Treatment Services are coordinated and administered by ASH. American Specialty Health Incorporated and its subsidiaries are one of the nation’s premier independent and privately-owned specialty health services organizations, providing specialty health care networks and programs, fitness and exercise programs and population health solutions. Through its subsidiaries, ASH administers programs for nearly 34 million members and contracts with more than 32,000 health care practitioners and service providers. For specific benefits and coverage provided for these services, please refer to the Evidence of Coverage and Disclosure section under the For Members page. 

  • For information on chiropractic and acupuncture services, call ASH customer service toll free at (800) 678-9133 (TTY/TDD: 711) or email them at service@ashn.com. Member Service Hours are as follows:
    M-F: 4am - 8pm Pacific Time 
    Sat: 12pm - 8pm Pacific Time
  • Please visit ASH Participating Provider to search for a provider on line

Utilization Management Policies

Policy Number and Name

Summary

 

 

Seaside ensures the availability of, and accessibility to, emergency health care and mental health care services within the service area twenty-four (24) hours-a-day and seven (7) days-a-week.

Seaside ensures that providers are reimbursed for emergency services and care provided to members, until the care results in stabilization of the member and
Seaside shall not require a provider to obtain authorization prior to the provision of emergency services and care necessary to stabilize the member's emergency
medical condition.

 

 

Seaside staffing structure include staff to perform the following functions; Special Needs Plan (SNP) coordination, data analysis, utilization coordination and training.

Seaside assures that staff coordinates benefits, information, and data collection and analysis for beneficiaries and network providers.

 

 

Seaside makes a special effort to coordinate care for Members enrolled in Special Needs Plans, when Members move from one setting to another, such as when they are discharged from a hospital. Without coordination, such transitions often result in poor quality care and risks to patient safety. The Care Transition Process is focused on managing planned and unplanned care setting transitions, identifying unplanned transitions and reducing transitions.

The purpose of this policy is to set forth guidelines for Seaside individuals in managing safe care setting transitions, identifying planned and unplanned transitions, and reducing transitions. Activities include but are not limited to, educating the member and responsible parties and coordinating services for members at high risk of problems with transition and to ensure the Members have a consistent person or unit responsible for supporting the Member and managing care transitions.

 

The CMS Model of Care defines that care is coordinated for Special Needs Plan (SNP) members through an interdisciplinary care team (IDCT) to address the  members’ medical, cognitive, psychosocial, and functional needs. Each Seaside SNP member is assigned to an interdisciplinary care team composed of primary, ancillary, and specialty providers appropriate for the population. The interdisciplinary care team is responsible for overseeing, coordinating, and evaluating the care delivered to assigned members.

The purpose of the Special Needs Program Interdisciplinary Care Team Coordination of Care policy is to provide the specific requirements for defining the team assigned to each SNP member, the roles of the team, and the instructions for how the team will coordinate and evaluate care delivered to assigned SNP members.

 

 

Seaside Utilization Management (UM) Program assures the delivery of medically necessary, optimally achievable, quality patient care through appropriate utilization of resources in a cost effective and timely manner.

Seaside UM Program has established processes by which the Plan prospectively, retrospectively, or concurrently reviews and approves, modifies, delays, or denies, based in whole or in part on medical necessity, requests by providers/practitioner of health care services for plan members. These processes ensure that decisions based on the medical necessity of proposed health care services are consistent with criteria or guidelines that are supported by clinical principles and processes.

 

 

 

The Plan policy on the Separation of Medical Services from Fiscal and Administrative Management is distributed via the Internet, written notification to all participating practitioners of the availability of the information on the Provider Portal website and paper copies upon request.

Seaside requires providers, practitioners and staff who participate in UM and Claims processes to sign the Separation of Medical Services from Fiscal and Administrative Management Acknowledgement at least every 2 years.

 

 

Seaside UM Program details decision making, turn-around time frames, UM criteria, communication of UM decisions, terminal illness requirements to ensure processing of request for referral authorizations will not interfere with or cause delay in service, or preclude delivery of services. These processes ensure that decisions based on the medical necessity of proposed health care services are consistent with criteria or guidelines that are supported by clinical principles and processes.

Referral Processes are consistent with Seaside UM Program. Decision making, turn-around time frames, UM criteria, communication of UM decisions and terminal illness requirements are followed per the UM Program to ensure processing of request for referral authorization will not interfere with or cause delay in service or preclude delivery of service.

 

 

Seaside implements a tracking system for all UM Referrals for documentation/identification of request status.

Seaside tracks referral services ensuring that necessary services were obtained, and follows up on the status of unused or expired referrals to ensure that the member’s ongoing need for care has been met.

 

 

When Seaside denies, defers, modifies, delays or terminates a request by a provider for medical services, Seaside notifies Members and Providers in a consistent and timely manner,

Providers are involved in development and/or adoption of criteria used for modifying, deferring or denying requested services.  Providers are encouraged to participate in Seaside’s Utilization Management (UM) meetings when UM guidelines (Milliman Care) are discussed.

 

 

Seaside, under its delegated agreements with Managed Medi-Cal Primary Plans, does not cover some specialized programs but instead the programs are covered and coordinated through the Medi-Cal fee-for-service (FFS) programs:

 

 

The California Children Service (CCS) Program provides medically necessary services and case management for Medi-Cal beneficiaries with:  CCS-eligible conditions or diagnoses who meet program eligibility requirements.

CCS services are excluded (“carved-out”) to Medi-Cal. Seaside participating providers are responsible for performing preliminary baseline health assessments and diagnostic evaluations to ascertain evidence or suspicion of a CCS-eligible condition or diagnosis.  Potentially eligible members are referred to the local CCS Program for eligibility determination, comprehensive case management and prior authorization of services.

Seaside complies with all CMS requirements related to approved benefits including the use of approved Medicare-certified facilities for performing certain surgical procedures.

 

 

Seaside Medi-Cal and Healthy Families participating primary care physicians (PCPs) are required to adhere to the (CHDP) Program requirements by providing early and periodic screening, diagnosis and treatment for Medi-Cal and Healthy Families members under age 21 according to CHDP Program guidelines.

 

 

The scope of this policy is limited to case management cases which are the responsibility of the health plan and where Seaside has not been delegated for case management. Seaside complies with requirements of contracted Health Plans and refers case management cases, when applicable to the responsible Health Plan.

Seaside refers Complex Case Management cases to the Primary Plan within the Primary Plan’s set timeframe for identification.

 

 

Seaside assists members in obtaining and utilizing community resources and social services through evaluation and identification of the member’s need for social services and community resources.

 

 

Seaside has a model of care to manage the delivery of specialized services and benefits for:

  • Dually-eligible special needs individuals
  • Medically complex or multiple chronic conditions
  • Individuals or near the end-of-life

 

 

Seaside provides reimbursement for Reconstructive Surgery that meets the Primary Plan’s definition.

Seaside does not reimburse for Cosmetic Surgery as defined by the Primary Plan.

For Medicare Advantage members, Medicare generally does not cover cosmetic surgery unless it is needed because of accidental injury or to improve the function of a malformed part of the body. Medicare covers breast reconstruction if a member has had a mastectomy due to breast cancer.

Questions about Seaside Health Plan?

Call Us at (855) 367-7747