John Muir Health logo
  • Patients
    About MyChart
    Locating Patients
    Medicare
    New Patients
    Payment & Insurance
    Physician Open Payments Notice
    Preparing for Surgery
    Pre-Register for a Visit
    Registration & Forms
    Request a Health Record
    Security Center
    Video Visits
    Why Choose Us
  • Services
    Addiction Medicine
    Behavioral Health
    Cancer
    Cardiovascular Services
    Digestive Health
    Emergency Services
    Lab Services
    Medical Imaging
    Neurosciences
    Orthopedics
    Pediatrics
    Physical Rehabilitation
    Pregnancy & New Parent
    Primary Care
    Urgent Care
    ALL SERVICES
  • Education
    Classes, Screenings & Support Groups
    Clinical Trials
    Conditions & Treatments
    Health & Wellness
  • Health Professionals
    Careers
    Clinical Research
    Family Medicine Residency Program
    John Muir Medical Group
    Medical Staff
    Nursing
    Pharmacy Residency Program
    Resources
    Training & Education
    Video & Publication Center
  • About Us
    Annual Reports
    Awards & Recognition
    Board of Directors
    Community Commitment
    Employers, Brokers, & Health Plans
    Executive Team
    Make a Gift
    Mission & Vision
    Partnerships
    Media Center
MyChart Login
  • Find a location
  • Find a doctor
  • Pay a bill
  • Find a job
✕

Latest information on COVID-19 >

Utilization Review Process

  1. Home
  2. For Patients & Visitors
  3. Payment and Insurance
  4. HMO Member Resources
  5. Utilization Review and Medical Review Guidelines
HMO Member Resources
  • About Our Care
  • About Us
  • Appeals and Second Opinions
  • Benefits of Membership
  • Durable Medical Equipment
  • Frequently Asked Questions
  • How to Pick a Doctor (PCP)
  • Physician Network Provider Directory
  • Referrals and Authorizations
  • Tips for Working with Your Healthcare Team
  • Utilization Review and Medical Review Guidelines
  • Vision Benefits

Utilization Review Process

Service authorization ensures that medically necessary services are provided at the most appropriate level for the John Muir Health Physician Network HMO members.  John Muir Health 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 Health 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, TTY/TDD users may call 711.

Medical Review Criteria

John Muir Health 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, members, and the general public upon request. Request for criteria can be made in writing, by fax or by telephone. Please submit written requests to:

John Muir Health Physician Network
Care Management Department
1450 Treat Blvd. #300
Walnut creek, CA 94598

The numbers for telephone or fax requests are:

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

Hi! I'm here to help answer your questions.
Chat
ABOUT
About Us
Board of Directors
Executive Team
Awards & Recognition
Partnerships
Community Commitment
Employers, Brokers & Health Plans
NEWS & PRESS
Media Center
Annual Reports
GET INVOLVED
Careers
Volunteer
Make a Gift
CONTACT
Email Us
PRIVACY
Patient Privacy
Website Privacy
Terms of Use
Security Center
Follow Us

© John Muir Health All rights reserved.

John Muir Health is accredited by The Joint Commission. 

We use cookies to measure website traffic and personalize content for a better browsing experience. By using this website, you consent to our cookies. For more details, see our Website Privacy Policy.