Utilization Management

Nivano Physicians delivers comprehensive Authorization and Utilization Management services led by experienced healthcare professionals who navigate the complexities of medical necessity, health plan policies, and regulatory requirements.

Using evidence-based guidelines, we ensure timely prior authorizations, coordinated care, and compliance with Medicare, HMOs, and PPOs—reducing administrative burdens and supporting optimal outcomes for both patients and providers.

Prior Authorization and Medical Necessity Review Services

Our utilization management professionals apply evidence-based clinical guidelines when prior authorization for physician services is required. Medical necessity determination is based on comprehensive review and evaluation of information submitted from requesting physicians and existing medical records.

Specific care and treatment authorization may vary depending on individual patient needs and benefits covered under each health plan. These criteria are available upon request for specific treatments.

Why Choose Us?

Experience the Nivano Difference in Healthcare

At Nivano Physicians, we understand that effective utilization management is about more than just approvals—it’s about ensuring timely, medically necessary care without unnecessary administrative delays. Our experienced team brings extensive knowledge of Medicare guidelines, commercial insurance protocols, and clinical best practices, making us a trusted partner for both providers and patients.

We take pride in our evidence-based approach, using established clinical criteria to guide every coverage determination. Our commitment to transparency means that financial incentives are never tied to medical necessity decisions, protecting the integrity of patient care. With 24/7 electronic access, responsive support, and a clear focus on compliance and quality assurance, Nivano Physicians simplifies the prior authorization process while supporting optimal health outcomes.

Highly-Qualified Professionals

Board-certified physicians committed to exceptional patient care.

Top-of-the-line Equipment

Advanced medical technology for accurate diagnosis and treatment.

Fast and affordable services

Efficient scheduling with competitive pricing and quality care.

Satisfaction Guaranteed

High patient satisfaction through personalized, responsive service.

Comprehensive Review Process and Healthcare Compliance

Our utilization management services include prospective review, concurrent review, and retrospective review processes to ensure appropriate care coordination and healthcare cost management. We maintain strict compliance with Medicare coverage guidelines, state insurance regulations, and HIPAA requirements. The use of financial incentives for utilization management programs or coverage determinations is specifically prohibited under Nivano Physicians contracts, ensuring that medical necessity decisions are based solely on clinical criteria and patient care needs.

Medicare Advantage and Insurance Authorization Support

We provide specialized authorization services for Medicare Advantage plans, traditional fee-for-service Medicare, and commercial insurance providers. Our team understands the unique requirements of different provider networks and works diligently to obtain necessary approvals for diagnostic procedures, specialized treatments, and medical equipment. For Medicare Advantage and Aetna Medicare authorization requests, providers can contact us at (916) 407-2000 ext 2512 for dedicated utilization management department support.

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Explore Medicare Advantage plans that include Nivano Physicians—an Independent Physician Association with 400+ primary care physicians, 1,200+ specialists, and 89 urgent care centers across Northern California.

Annual Enrollment Period ends Dec. 7th.

Or Call (916) 407-2000 ext. 2512

24/7 Electronic Communication and Provider Access

Healthcare providers have access to our utilization management services 24 hours a day through electronic communication systems, with physical receipt of documentation occurring on the next business day.

Our normal business hours are Monday through Friday, 8:00 AM until 5:00 PM, based on delegated responsibilities and regulatory requirements.

For urgent authorization requests and case management needs, providers can utilize our portal submission system at portal.promisecare.com or contact our dedicated authorization hotline at (916) 407-2000.

How Can We Help

Streamlined Authorization Support for Compliant, Patient-Centered Care

Our utilization management services ensure healthcare compliance while facilitating timely access to medically necessary care. We help providers navigate complex prior authorization requirements, reduce administrative burdens, and maintain quality patient care coordination. Our experienced team works with health maintenance organizations, preferred provider organizations, and Medicare Administrative Contractors to streamline the appeals process and ensure appropriate coverage determination for all patients.

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After-Hours Support and Voice Mail Services

The Utilization Management Department maintains a dedicated voice mailbox to accept after-hour messages and urgent authorization requests.

All calls are returned the following business day during the week, with Sunday messages returned on Monday morning.

This ensures continuous support for healthcare providers and patients requiring assistance with coverage determination and appeals process navigation.

Our commitment to accessibility extends to electronic communication capabilities 24 hours per day for optimal case management support.

Authorization Request Forms and Documentation

Healthcare providers can access Authorization Request Forms and submit required documentation through multiple channels. For standard authorization requests, use our secure portal at portal.promisecare.com or contact our utilization management team directly.

Please note: DO NOT SEND AUTHORIZATION REQUESTS TO EMAIL addresses – use designated phone lines and portal systems for secure transmission of medical necessity documentation and prior authorization materials.

Nivano Physicians Patient Testimonials

At Nivano Physicians, patient well-being is our top priority. We’re proud to support thousands of Californians with coordinated, compassionate care—and our patients say it best.

Help When I Needed It Most

“When I needed approval for a specialist visit, Nivano’s team handled everything quickly and professionally. It gave me peace of mind during a stressful time.”

Linda T.

Smooth and Simple Process

“I was nervous about getting prior authorization for my treatment, but Nivano made the process smooth and easy. I’m thankful for how well they communicated with my doctor.”

Robert J.

Real People Who Care

“Every time I called, I spoke with someone who listened and helped. It’s rare to feel that cared for by a healthcare organization—but Nivano delivered.”

Angela M.

Say Hello

Quality Assurance and Patient Protection Measures

Nivano Physicians maintains strict quality assurance protocols to ensure that utilization management decisions support appropriate patient care while preventing unnecessary healthcare costs.

Our program specifically prohibits the use of bonuses or incentive pay to influence practitioner decisions regarding medical necessity.

Financial incentives for utilization management are not linked to decisions that result in under-utilization, ensuring that coverage determination is based solely on clinical guidelines and evidence-based criteria for optimal patient outcomes.

GOT QUESTIONS?

Check Out Our FAQs

What is utilization management and how does it affect my healthcare coverage?

Utilization management is a healthcare process that evaluates the medical necessity, appropriateness, and efficiency of treatments, services, and procedures on a case-by-case basis. At Nivano Physicians, our utilization management services ensure that patients receive medically necessary care while maintaining compliance with insurance requirements and clinical guidelines. For questions about coverage determination, contact our team at (916) 407-2000.

How long does the prior authorization process typically take?

Prior authorization timelines vary depending on the complexity of the request and specific insurance requirements. Our utilization management team works diligently to process authorization requests promptly during normal business hours (Monday-Friday, 8 AM to 5 PM). For urgent requests, we provide expedited review processes and can be reached at (916) 407-2000 for immediate assistance.

What information is needed for a successful authorization request?

Successful prior authorization requires comprehensive medical documentation, clinical justification for medical necessity, and specific treatment details. Our utilization management professionals review all submitted information according to evidence-based criteria and clinical guidelines. Healthcare providers should submit complete documentation through our secure portal at portal.promisecare.com or contact our authorization department at (916) 407-2000.

Do you provide authorization services for Medicare Advantage plans?

Yes, Nivano Physicians provides specialized utilization management services for Medicare Advantage plans, traditional Medicare, and commercial insurance providers. Our team understands the unique requirements of different provider networks and Medicare Administrative Contractors. For Medicare Advantage and Aetna Medicare authorization requests, contact our dedicated line at (916) 407-2000 ext 2512.

What happens if my authorization request is denied?

If an authorization request is denied, our utilization management team provides detailed explanation of the denial reasons and assists with the appeals process. We work with healthcare providers to gather additional documentation or modify treatment plans to meet medical necessity criteria. Our patient advocacy approach ensures that coverage determination decisions support optimal patient care coordination and compliance with healthcare regulations.

Can I contact the utilization management department after business hours?

While our normal business hours are Monday through Friday, 8 AM to 5 PM, we provide after-hours support through our voice mail system. Electronic communication is available 24 hours daily, with physical receipt of documentation occurring the next business day. For urgent authorization needs, leave a detailed message and our team will respond the following business day, with Sunday messages returned on Monday morning.

How does Nivano Physicians ensure quality and compliance in utilization management?

Our utilization management program maintains strict adherence to healthcare compliance standards, including HIPAA requirements, state insurance regulations, and Medicare coverage guidelines. We prohibit the use of financial incentives that could influence medical necessity decisions, ensuring that all coverage determinations are based solely on clinical criteria and evidence-based guidelines. Our quality assurance measures protect patient interests while supporting appropriate healthcare cost management.