Utilization Management
Nivano Physicians offers Authorization/Utilization Management services delivered by health care professionals. Our professionals are trained in the health plan’s policies and procedures as well as applicable regulatory agency requirements.
These guidelines are applied when a prior authorization for a physician service is needed. Determination of authorization is based on review and evaluation of information submitted from the requesting physician and/or obtained from review of existing medical records. Specific care and treatment authorization may vary depending on individual need and benefits covered under the individual’s plan. These criteria are available on request for specific treatment. The Utilization Management department can be reached Monday through Friday from 8 am to 5 pm at 916.407.2000 or our toll free line at 844.889.2273. Then, press 2 for Authorizations.
The use of incentives for its utilization management programs or coverage determinations is specifically prohibited under Nivano Physicians contracts. Bonuses or incentive pay may not be used in any way to influence a practitioner’s decision to withhold, delay or deny necessary medical services. Any financial incentives used for utilization management are not linked or used to encourage decisions that result in under-utilization.
Nivano Physicians Medical Group has processes in place to provide access to staff for members and practitioners seeking information about the Utilization Management (UM) process and the authorization of care. Utilization Management Member Services staff are available at least eight hours a day during normal business hours to receive inbound communication regarding UM issues. They can be reached at 844.889.2273. Member services staff are authorized to accept collect calls from members regarding UM issues. The UM Department has a voice mailbox to accept after hour messages. Calls are returned the following business day during the week. Sunday messages are returned on Monday morning.
Anthem Medicare and Aetna Medicare Authorization Request Form :
279-399-2709 for other UM Department
Providers have access 24hrs, email um@nivanophysicians.com (DO NOT SEND AUTHRORIZATION REQUEST TO EMAIL)
Nivano Physicians normal business hours are set based upon delegated responsibilities and are currently Monday through Friday, 8:00 AM until 5:00 PM. NIVANO physicians’ staff can receive inbound communication regarding UM issues after normal business hours. They are able to receive electronic communication 24 hours per day with physical receipt of documentation occurring on the next business day.
Portal Submission link : Portal.promisecare.com
