Nurse advice lines are available from health plans for qualified and eligible members. Primary care practices are encouraged to share this information with patients so they can access these services.

Alignment Health Plan

1-844-323-2247

Champion Health Plan

1-800-885-8000

Health Net

1-800-675-6110

Utilization Management

Clinical Criteria and Hierarchy

When making a determination, CHS IPA applies clinical criteria in the order shown below, starting with the primary source.

Medi-Cal

DHCS criteria is the primary source.

Medicare Advantage

CMS is the primary source.

1. National Coverage Determinations (NCD)
2. Local Coverage Determinations (LCD)
3. Local Coverage Articles (LCA)
4. Medicare Manuals: Medicare Managed Care, Medicare Benefit Policy, Medicare Program Integrity, Medicare Claims Processing
5. Health plan criteria
6. Evidence-based criteria, such as Milliman Care Guidelines (MCG)

A copy of the criteria used to make a determination is available upon request.

Resources

Additional UM Resources

Regulatory guidance and health plan guidelines referenced in utilization management decisions.

Regulatory Guidance

Health Plan Guidelines

Alignment Health Plan

Champion Health Plan

Health Net

Questions about these resources or a utilization management decision? Our team is here to help.