There are lots of new developments in medical technology and treatments including new drugs. Many times, new developments lead to better quality of care. Some treatments need to be tested in studies to make sure they are safe. PHC's Technology Assessment Policy describes how the HealthPlan considers new technology. A group of doctors and pharmacists who work with our members decide if there is good scientific proof that a new treatment is better than or equal to those already in use. They also decide if an already approved treatment can be used in other ways. These guidelines are always used.
The treatment must be safe. The benefits must be greater than any side effects or risks. It must also be approved by safety groups, such as the Federal Drug Administration (FDA).
The treatment must be effective. Does it work? Does it improve the member's health and quality of life?
The treatment must have value. If the cost is more than technologies being used, are the benefits also greater?
The treatment must be medical in nature. If the treatment is more for convenience or is cosmetic the new technology would not be approved.
The group picks members who would gain most from a new treatment and makes guidelines on the best way to use treatment.
PHC'S Utilization Management (UM) program
PHC's Utilization Management ("UM") Program handles all Referral Authorization Forms (RAF's) and Treatment Authorization Requests (TAR's). Your primary care provider uses a RAF to refer you to a specialist for one or more visits. Health providers use a TAR to get PHC's pre-approval for some surgeries, wheelchairs, and other services. These health services need to be approved by PHC for medical necessity. PHC answers TAR's within five working days unless more information is needed. If a TAR is not approved, you will get a letter. You may file a grievance or a State Fair Hearing if your TAR is denied and you don't agree with the decision. If you have questions, call the PHC Member Services department at (800) 863-4155.
Care that is Right for You
Partnership HealthPlan of California wants you to get the care you need. Decisions made by PHC's Utilization Reviewers are based only on the appropriateness of care or service. Utilization Review means that the HealthPlan reviews the care you have gotten or may get. The Health Plan does not pay for any individual involved in the Utilization Review process to deny care or services to our members. PHC does not encourage or offer incentives for denial of care.