Service authorization ensures that medically necessary services are provided at the most appropriate level and match the health plan benefits. The John Muir Physician Network makes the following affirmations regarding the care management process:

• Utilization Review decision making is based only on appropriateness of care and service.
• The John Muir Physician Network does not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service.
• Financial incentives for utilization review decision makers do not encourage decisions that result in under-utilization.

The John Muir Physician Network utilizes written criteria based upon sound clinical evidence in the review of requests for medical services. Criteria are consistently applied to service requests based upon the needs of each individual patient. The criteria utilized in the review process of a specific request are available to providers and members upon request. Request for criteria can be made in writing, by fax, or by telephone. Please submit written requests to:

John Muir Physician Network
Care Management Department
1340 Treat Blvd, Suite 450
Walnut Creek, CA 94597

For questions regarding the care management process or criteria, please contact Customer Service at (925) 952-2887.

Second Opinions

As a patient, you have the right to obtain a second opinion. If there is a procedure that the Care Management Department declined to authorize because it is not considered medically necessary, you may obtain a second opinion from a contracted or non-contracted physician. If you wish to obtain a second opinion from a provider not contracted with the John Muir Physician Network, you must contact your health plan for authorization of the consultation.

Out of Network Policy

As an HMO patient with the John Muir Physician Network you have access to a full array of excellent Primary Care Physicians, Specialty Physicians, hospitals, surgery centers, and ancillary service providers. Your health plan has recognized the value of the John Muir Physician Network because of these health care providers. To make the health care delivery system function as intended and as efficiently as possible, we require our patients to utilize these network providers whenever possible.

Requests for authorization to be treated by an out-ofnetwork provider must be submitted to the John Muir Physician Network by your physician. The John Muir Physician Network will authorize those requests that are clinically appropriate and cannot be provided within the John Muir Physician Network. Claims submitted for unauthorized out-of-network services will be denied and may become your financial responsibility. The out-ofnetwork providers have been advised of this policy and may require you to sign an agreement accepting financial responsibility if you do not have the appropriate authorization for their services.

You can access the John Muir Physician Network's list of in-network HMO providers by visiting our Find a Physician page. You can use the drop down tabs to find one of our Primary Care Physicians or in-network Specialists. Click on the "Hospitals/Other Facilities" tab to access our other in-network HMO providers; including our network urgent care centers, out-patient surgery centers, laboratories, rehabilitation centers and more. You can also verify the in-network status and location of a provider by calling the Customer Service Department at (925) 952-2887.

Appeals

The John Muir Physician Network defines an appeal as the written process in which you disagree with a decision. Patients have the right to appeal denials directly to their health plans. Contact Customer Service at the John Muir Physician Network for instruction on filing an appeal for denied services.