The law does not prohibit providers/practitioners from billing with the SSN. Social Security numbers may be used for internal verification or administrative purposes, as long as the use does not result in the public display or disclosure of the number in violation of requirements. Utilization Management Medical TeamĪssociate Medical Directors: Allyson Kreshak, MD, Elizabeth Rosenblum, MD Confidentiality Utilization management criteria are available to the member, practitioner and public. All decisions are communicated to the requesting provider via EPIC, and member notification of decisions are sent via.We sometimes use the expertise of our medical specialists to assist in making determinations. The utilization management department consists of administrative data entry coordinators with extensive coding and clinic experience, registered nurses, and a board-certified medical director who oversees all medical decision-making.UC San Diego Health does not sub-delegate any decision making to any other entity.Financial incentives do not encourage decisions that result in under-utilization.We do not reward practitioners or others for issuing denials of coverage or service care.This process is based only on appropriateness of care and service and existence of coverage. Our utlization management department reviews requests for medical necessity and adherence with contractual agreements.During the Provider Escalation Project which ended in 2019. This would include as examples EOB 491 Gap in Billed Days, EOB 631 No Long Term Care on File, or EOB 916 RUG Cannot Be Determined. ![]() Timely filing exceptions are listed below under Timely Filing Requirements. The Managed Care team applies these policies when making decisions about insurance eligibility, authorization, referrals and claims: submitted to your Gainwell Provider Representative with proof of timely filing. We serve patients of these HMOs who receive primary care at UC San Diego Health: The UC San Diego Health Managed Care team oversees eligibility, pre-authorization, referrals and claims about HMO coverage and can answer questions such as:
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