UM Referral Process
- Contracted Providers can access Connect to submit referrals
- Non-contracted Providers can fill out the UM TAR Form. Please click here to access the form.
- To contact the UM Department, please call 855-848-5252 M – F 8 am to 5 pm
UM Clinical Criteria
Prescription Drug Form
- The Risk Bearing Organization (RBO), c/o Altura Management Services, UM decision making is based only on appropriateness of care, service, and the existence of coverage. Additionally, the RBO c/o Altura MSO affirms:
- It does not award practitioners or other individuals conducting utilization review decisions that result in underutilization.
- UM decision making is based only on appropriateness of care and service and existence of coverage.
- It does not specifically reward practitioners or other individuals for issuing denials of coverage.
- Financial incentives for UM decision-makers do not encourage decisions that result in underutilization.
- Providers and practitioners are not prohibited from acting on behalf of the member
- Physicians cannot be penalized in any manner for requesting or authorizing appropriate medical care.
- Practitioners are ensured independence and impartiality in making referrals decisions that will not influence the hiring, compensation, termination, promotion, or any similar matters.
Initial Health Assessment
- To obtain a copy of member medical records, please fax your request to Altura MSO at 323-530-5701.
- A "standing referral" is defined as, two (2) or more visits to a specialist Care.
- A condition or disease that requires specialized medical care over a prolonged period of time and is life threatening, i.e. degenerative, disabling HIV infection and AIDS, must receive a referral to a specialist or specialty care center for the purpose of having the specialist coordinate the member’s health care.
- To obtain a copy of the Standing Referral policy call the UM department at 855-848-5252 M – F 8 am to 5 pm
Provider Peer-to-Peer Requests
- Altura MSO UM Department has a designated phone line to connect providers with our Physician Reviewers.
- This phone line may be used to contact a physician reviewer to discuss adverse determinations
- Direct #: 323-597-2928
Comprehensive Perinatal Services Program (CPSP)
- Pregnant women who are eligible for Medi-Cal can enroll in CPSP, which includes prenatal medical care, health & nutrition education, as well as support for issues like jobs, emotional well-being, and housing.
- Pregnant women and teens can go to CPSP sites and receive temporary Medi-Cal that same day for prenatal care. The patient must then apply for Medi-Cal. No one is excluded based on immigration status. While waiting for the reply from Medi-Cal, the clinic visits will be paid for by Medi-Cal.
- For additional program information, visit the CPSP Website
- To obtain a copy of the CPSP Provider Handbook, please click here.
- To obtain a copy of the CPSP Program Guidelines, please click here.
Case Management Referral Process
- Referrals to Case Management (CM) will be accepted via telephone, or e-mail.
- Telephone: 855-848-5252 M – F 8 am to 5 pm
- E-Mail: email@example.com
- Providers can access the CM Referral Form here.
- Hospital/Emergency Room attempting to provide telephonic notification for post-stabilization must call 855-848-5252 to obtain authorization of post-stabilization care.
- Upon calling, follow the prompt selections to the Inpatient Department as a UM representative is available 24 hours a day, 7 days a week.
Sterilization and Informed Consent
- All members undergoing sterilization must give written consent via the PM 330 form and receive a copy of the Sterilization Booklet from the DHCS website.
- In addition to the PM 330 consent form, a member acknowledgment must be documented in the electronic medical record (EMR) confirming receipt of the booklet by the member.
- To obtain a copy of the Sterilization Booklet, please visit the DHCS website
- To obtain a copy of the PM 330 form, please click here.