Please see below for details on utilization management and clinical resources for your patients. If you need additional assistance, please Contact Us.
Certain health care services require Prior Authorization by the Medical Group or MemorialCare Select Health Plan (MCSHP) in order to be covered. Primary Care Physicians must contact MemorialCare Select Health Plan 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 MCSHP or the Medical Group or Windstone, as applicable. Please contact MemorialCare Select Health Plan Member Services for additional information regarding services that require prior authorization.
Utilization Management Criteria
MemorialCare Select 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
MemorialCare Select 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
To view the prescription drug formulary, please visit the Prescription Drug List section under the For Providers page.
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. 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:
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 firstname.lastname@example.org.
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|
(MCSHP UM 1500 S)
The program description includes the scope of the program and the process and information sources used to make determinations of benefit coverage and medical appropriateness.
(MCSHP UM 1507 S)
|MemorialCare Select Health Plan provides coverage for the diagnosis and medically necessary treatment of severe mental illnesses of a person of any age, and of serious emotional disturbances of a child under the same terms and condition.|
(MCSHP UM 1503 S)
|MemorialCare Select Health Plan transplant program covers the professional and institutional costs of solid organ, cornea and stem cell transplant for members when medically necessary and not considered experimental or investigative.|
(MCSHP UM 1501 S)
|When requested by a Member or participating provider who is treating a Member, MemorialCare Select Health Plan or its delegate shall provide or authorize a second opinion by an appropriately qualified health care professional.|