COMMUNITY EVENTS

HEALTH EDUCATION

WHAT IS AN IPA?

UTILIZATION MANAGEMENT

PCAMG's Care Management Team is comprised of non-clinical staff, licensed nurses and Medical Directors. Together they make sure that recommendations from your provider are:

• covered by your health plan
• provided by a physician or in a facility that has been contracted and credentialed by PCAMG
• medically appropriate

To determine that all these factors have been met, PCAMG/s Care Management Team reviews each request submitted by a provider along with medical records and relevant coverage policies developed by your health plan. Additionally, the Care Management Team will also review national standards of care such as Milliman Care Guidelines if these are available.

Once the decision of the provider's request has been determined by the PCAMG Care Management Team, a letter will be mailed to both you the member and the requesting provider with the decision and the explanation of how the decision was determined. The letter will also include instructions on how you can file an appeal if you disagree with the decision.

To request a copy of the coverage policy or standards PCAMG Care Management Team uses in determining the outcome of provider recommendations, you may call us at: (760) 471 - 9444. 

Medical Policies are also available to the general public and can be obtained by reaching us at: (760) 471 - 9444.