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Utilization Review

San Jose Medical Group’s Utilization Review Department processes authorization requests submitted by your physician. This procedure helps to ensure proper utilization of available resources and appropriate case management. Any requests for services are to be generated by your physician. The request is reviewed for medical necessity and may be approved, modified or denied. If the request is denied, alternative treatment measures are recommended to your physician. Should you wish to appeal the decision, the appeal process is outlined in the denial letter you receive.

Managed Care physicians and healthcare professionals who make utilization management related decisions are required to do so, based on appropriateness of care and service for the member’s medical needs. San Jose Medical Group does not specifically compensate practitioners or other individuals for issuing denials of coverage or service. San Jose Medical Group does not use financial incentives to encourage inappropriate utilization nor does it encourage decisions that result in underutilization. This is in accordance with the National Committee on Quality Assurance (NCQA) standards.

Requests for clinical criteria should be directed in writing or by telephone to:

San Jose Medical Group
Utilization Management Department
400 Race Street, CA 95126
408 278 – 3070

San Jose Medical Group Utilization Management (UM)Department

Phone: 408 278 3070
Toll Free Number: 800 970 7757
Fax: 408 278 3188

*Calls made to UM after hours, weekends and holidays can be left on the confidential UM voice mail system. Calls will be picked up and returned the next business day.