Utilization Management (UM) decision making is based only on appropriateness of care and service and existence of coverage.
Avanta IPA does not specifically reward practitioners or other individuals for issuing denials of coverage or service care.
Avanta IPA does not offer financial incentives to UM decision makers that encourage decisions that result in underutilization.
Our practitioners are ensured independence and impartiality in making referral decisions that will not influence hiring, compensation, termination, promotion, any other similar matters.
Members and Providers may request a copy of the criteria used in the decision-making process by calling us at the number below or by fax.
Fax: (714) 422-0633
Call the TTD/TTY number on your Member ID card or dial 711 for
Telecommunications Relay Service
Utilization Management Staff are available from 8:00 am –5:00 pm Monday through Friday to answer Member and Provider questions related to the authorization and referral processes. An After-Hour nurse is available after 5:00pm to assist Members after normal business hours, Weekends and Holidays.