Important information for your health.  
 
The Utilization Management Program (UMP) is designed to monitor, evaluate, and manage the cost and quality of healthcare services delivered to all members of St. Joseph Heritage Medical Group (SJHMG).

This is achieved through a comprehensive process in which review of inpatient and outpatient services are performed in accordance with the requirements of the contracted payors, the Knox-Keene Health Care Services Plan Act of 1975, its amendments, the National Committee for Quality Assurance (NCQA), Department of Health Services (DHS), Department of Managed Health Care (DMHC), Centers for Medicare & Medicaid Services (CMS), local, state and federal regulations, Milliman Care Guidelines and Interqual Care Guidelines.  The process is to assure the delivery of medically necessary and high quality patient care through appropriate utilization resources in a cost effective and timely manner. The focus of the program is to ensure efficiency and continuity in this process by identifying, evaluating, monitoring, and correcting elements that affect the overall effectiveness of the utilization management process. The program's activities are developed and implemented in compliance with state and federal regulations, as well as the managed care requirements and are approved by the Board of Directors.  Utilization Management decision guidelines are available to members and providers upon request.

The program is designed to monitor, evaluate and manage the quality and timeliness of healthcare services delivered to all St. Joseph Heritage Medical Group members.
The program provides fair and consistent evaluation of the medical necessity and appropriateness of care through the use of nationally recognized standards of practice and internally developed clinical practice standards.

Network practitioners are included in the Utilization Management and Quality Management process through participation in various committees, which are functional components of the program.

SJHMG providers do not receive incentives for decisions related to utilization/referral authorizations. Providers may freely discuss with members available and appropriate treatment options, regardless of the cost or benefit coverage.