REFERRALS AND AUTHORIZATIONS
CASE MANAGEMENT REFERRALS
A completed Case Management Referral Form is required when electing patients for case management services. Case management can only be provided with confirmed eligibility and the member’s consent.
Download an AAMG Case Management Referral Form
AUTHORIZATIONS
A completed Service Authorization Request Form is required for all referrals made to out-of-network providers. Services from out-of-network providers can only be provided with an approved service authorization request.
Additional limitations may apply and require a service authorization request as outlined in our provider manual. For a copy of our provider manual, please contact our Provider Relations Department at (415) 216-0093.
Download an AAMG Authorization Request Form
AFFIRMATION STATEMENTS
AAMG compensation to providers, employees, or other individuals conducting utilization reviews on its behalf does not contain incentives, direct or indirect, to approve or deny payment for the delivery or result in underutilization of any healthcare service. Utilization-related decision-making is based on the individual clinical needs of the member, benefit availability, medical appropriateness of care and service, and the existence of coverage. All clinical reviewers attest to this statement upon hire.
Download an Affirmation Statement Form
The criteria or guidelines used by AAMG, or any entities with which the medical group contracts for services that include utilization review or utilization management functions, to determine whether to authorize, modify, or deny health care services shall:
(1) Be developed with the involvement of actively practicing health care providers.
(2) Be consistent with sound clinical principles and processes.
(3) Be evaluated and updated, if necessary, at least annually.
(4) If used as the basis for a decision to modify, delay, or deny services in a specified case under review, be disclosed to the provider and the enrollee in that specified case.
(5) Be available to the public upon request. AAMG shall only be required to disclose the criteria or guidelines for the specific procedures or conditions requested. AAMG may charge a reasonable fee to cover administrative expenses related to disclosing criteria or guidelines pursuant to this paragraph, limited to copying and postage costs. AAMG may also make the criteria or guidelines available through electronic communication means.
Reference: CAHSC 1353.5(b)