Case Management
Utilization Management Services
Sutter Health Sacramento Sierra Region
Sutter Health Sacramento Sierra Region (SHSSR) Continuum Case Management provides utilization management (UM) services for Health Maintenance Organizations (HMO) health plans contracted with Sutter Independent Physicians (SIP), Sutter Medical Group (SMG), and Sutter West Medical Group (SWMG).
SHSSR's UM program is designed to monitor, evaluate, and manage the cost and quality of healthcare services delivered to all members of SIP, SMG, and SWMG. The UM department performs prospective, concurrent, and retrospective review of services requested by health care providers using nationally accepted criteria and informational resources to determine the appropriateness of healthcare services.
All practitioners, providers, and UM staff involved in UM decision making processes are required to sign affirmation statements regarding confidentiality and incentives. The statement acknowledges the following for UM decision makers:
- UM decision-making is based only on appropriateness of care and service and existence of coverage.
- The UM organization does not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service care.
- Financial incentives for UM decision makers do not encourage decisions that result in under utilization.
SHSSR Case Management undergoes annual HMO UM oversight audits to ensure compliance with state and federal regulatory requirements.
Practitioners, providers, members, or member's representatives can contact SHSSR Case Management directly at (916) 643-6500 or toll free through customer service at (888) 516-8023 to inquire about UM processes, affirmative statements, or criteria/guidelines.