Access to Care Standards
Case Management Program
HealthNet and SCAN Model of Care Training for SNP
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)
US Preventative Task Force Guidelines
- Clinical Criteria Request Form (Do not use for Prior Authorization Requests)
- Medical Group Referral Form
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.