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

SHP Select Utilization Management Program 

(SHP 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. 

SHP Select BHT for PDD or Autism 

(SHP UM 1507 S)

Seaside 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.

SHP Select Transplant Program 

(SHP UM 1503 S)

Seaside 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.  

SHP Select Second Opinion 

(SHP UM 1501 S)

When requested by a Member or participating provider who is treating a Member, Seaside Health Plan or its delegate shall provide or authorize a second opinion by an appropriately qualified health care professional.

Questions about Seaside Health Plan?

Call Us at (855) 367-7747