Utilization Review and Medical Review Guidelines

Utlization Review Process

Service authorization ensures that medically necessary services are provided at the most appropriate level for the John Muir Physician Network HMO members.  John Muir Physician Network makes the following affirmations regarding the utilization review process:

  • Utilization Review decision making is based only on appropriateness of care and service.
  • 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 underutilization.
  • Routine service requests are processed within 5 business days of receipt of all information necessary to make a determination.  Routine service requested received after 3:00 pm are considered to be received on the next business day.
  • Requests for medically urgent services are processed within 72 hours of receipt of the request.

For questions regarding the utilization review process, policies or decisions, please call (925) 952-2887 or (844) 398-5376, option 1, TTY/TDD users may call 711.

Medical Review Criteria

John Muir Physician Network utilizes written criteria based on sound clinical evidence in the review of requests for medical services.  Criteria are consistently applied to service requests based on the needs or each individual patient.

The criteria utilized in the review process of a specific request is 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

The numbers for telephone or fax requests are:

Telephone: (925) 952-2887 or (844) 398-5376, option 1, TTY/TDD users may call 711
Fax:  (925) 952-2865