Providers may obtain a copy of any benefit provision or criteria we use to make our utilization management decisions. Providers may also request criteria for authorizations managed internally by the Alliance.
To make a request, please call:
Providers may contact our delegated partners directly for a copy of the criteria used in their utilization management decisions.
All Alliance Utilization Management (UM) Department determinations are made based on consistently applied criteria. The criteria are selected based on nationally recognized and evidence-based standards of practice for medical services and are applied on an individual needs basis. Primarily, the Alliance uses criteria from Medi-Cal and MCG® Care Guidelines. If indicated, the Alliance may also conduct independent medical reviews.