Provider Tools

Access to Care Standards

• DMHC – Timely Access to Care 

Case Management Program

• Case Management Program

HealthNet and SCAN Model of Care Training for SNP

• HealthNet – Model of Care Training (PDF)
• Scan Health Plan – Model of Care Training

HIPAA

• HIPAA Notice of Privacy Practices

Medicare Fraud Waste and Abuse

• 2016 HCMG Fraud Waste and Abuse Training
• Medicare Learning Network® (MLN) Learning Management System (LMS)

Prescription Drug form (61-211)

• Prescription Prior Authorization Request Form

US Preventative Task Force Guidelines

• Electronic Preventive Services Selector
• Tools and Resources for Better Preventive Care 

Other/Miscellaneous

• Clinical Criteria Request Form (Do not use for Prior Authorization Requests)
• Medical Group Referral Form

Affirmative Statement

1.) Utilization Management decision-making is based only on appropriateness of care and service and the existence of coverage.
2.) The delegate does not specifically reward practitioners or other individuals conducting utilization reviews for issuing denials of coverage.
3.) Financial incentives for Utilization Management decision-makers do not encourage decisions that result in under-utilization.