Section 5: Utilization Management

Table of Contents - Medi-Cal

Policy/Procedure Title	Policy Number
Utilization Management Program Description	MPUD3001
Acupuncture Services Guidelines	MCUG3002
Acute Inpatient Administrative Days	MCUP3053
Appeals of Utilization Management / Pharmacy Decisions	MCUP3037
Provider Request for Appeal of UM Decision for Medical Necessity Determination	MCUP3037-A
Member Authorization for Provider Appeal	MCUP3037-B
UM Appeal Acknowledgement Letter	MCUP3037-C
Appropriate Service & Coverage (Over / Under Utilization)	MPUP3006
Authorization of Ambulatory Procedures and Services	MCUG3007
Treatment Authorization Request (TAR) Form Reference	MCUG3007-A
TAR Requirements	MCUG3007-B
Medical Necessity Critera for Pain Management Procedures	MCUG3007-C
Behavioral Health Treatment (BHT) for Members Under the Age of 21 (previously Autism Spectrum Disorder)	MPUP3126
CalAIM Community Supports (CS)	MCUP3142
Community Supports Criteria Matrix and Community Supports HCPCS Code Chart	MCUP3142-A
CalAIM Service Authorization Process for Enhanced Care Management (ECM) and/or Community Supports (CS)	MCUP3143
Community Supports Criteria Matrix and Community Supports HCPCS Code Chart	MCUP3143-A
Enhanced Care Management (ECM) HCPCS Code Chart	MCUP3143-B
Community Support Services Referral Form	MCUP3143-C
Cardiac Rehabilitation	MCUP3128
Chiropractor Services	MCUG3010
Communication Services	MCUP3064
Community Based Adult Services	MCUP3115
CBAS Individual Plan of Care (IPC) Form DHCS 0020	MCUP3115-A
Coordination of Care for Members in Foster Care	MCUP3103
Criteria and Guidelines for Utilization Management	MCUP3139
Table of Approved Criteria and Guidelines Referenced for Utilization Management	MCUP3139-A
Criteria for Home Health Services	MCUG3011
Delegation of Inpatient Utilization Management	MCUP3141
Dental Services (including Dental Anesthesia)	MPUP3048
Direct Members	MCUP3039
Direct Members Designation Grid	MCUP3039-A
Discharge Planning (Non-capitated Members)	MCUP3012
DME Authorization	MCUP3013
DME Rental Only	MCUP3013-A
DME Limited to Special Circumstances	MCUP3013-B
Oxygen (O2) Request Verification Form	MCUP3013-C
Certificate of Medical Necessity for all Durable Medical Equipment (DME)	MCUP3013-D
MTU DME Review Process and Example Form	MCUP3013-E
Eating Disorder Management Policy	MCUP3145
Eating Disorder Process Flow Chart	MCUP3145-A
Eating Disorder Bidirectional Form	MCUP3145-B
Emergency Services	MCUP3014
Evaluation and Management of Obstructive Sleep Apnea in Adults	MCUG3110
External Independent Medical Review	MCUP3138
Family Planning By-Pass Services	MCUP3015
Fecal Microbiota Transplant	MCUP3136
Gender Dysphoria / Surgical Treatment	MCUP3125
Genetic Screening and Diagnostics	MCUP3131
Genetic Testing Requirements	MCUP3131-A
Family History Screening Tool	MCUP3131-B
Health Services Review of Observation Code Billing	MPUP3018
Hearing Aid Guidelines	MCUG3019
Documentation for Authorization of Hearing Aids	MCUG3019-A
Hospice Services Guidelines	MCUP3020
Hospital Bed / Specialty Mattress Guidelines	MCUG3134
Incontinence Guidelines	MCUG3022
PHC Maximum/Average Benefit Guidelines	MCUG3022-A
Incontinence Supplies Medical Necessity Certification form (DHCS 6187)	MCUG3022-B
Inpatient Utilization Management	MCUG3024
Insulin Infusion Pump & Continuous Glucose Monitor Guidelines	MPUG3025
CCS NL 06-1120Authorization of Insulin Infusion Pumps – Revised 11/17/2022	MPUG3025-A
CCS NL 15-1222 Continuous Glucose Monitoring (CGM) Systems as a CCS/GHPP Program Benefit - Revised 12/23/2022	MPUG3025-B
Inter-Rater Reliability Policy	MPUP3026
Long Term Care SSI Regulation	MCUP3051
Medication Abortion in the First Trimester	MCUP3050
Mifepristone Patient Agreement Form - Danco	MCUP3050-A
Mifepristone Patient Agreement Form - GenBioPro	MCUP3050-B
Mifepristone Prescriber Agreement Form - Danco	MCUP3050-C
Mifepristone Prescriber Agreement Form - GenBioPro	MCUP3050-D
Mifepristone Pharmacy Agreement Form - Danco	MCUP3050-E
Mifepristone Pharmacy Agreement Form - GenBioPro	MCUP3050-F
Medical Nutrition Services	MCUP3052
Referral Guidelines for Children/Adolescents	MCUP3052-A
Referral Guidelines for Adults	MCUP3052-B
Adult Body Mass Index	MCUP3052-C
Mental Health Services	MCUP3028
Adult Screening Tool for Medi-Cal Mental Health Services	MCUP3028-A
Youth Screening Tool for Medi-Cal Mental Health Services	MCUP3028-B
Transition of Care Tool for Medi-Cal Mental Health Services	MCUP3028-C
Nebulizer Guidelines	MPUG3031
Negative Pressure Wound Therapy (NPWT) Device/Pump	MPUP3059
Neonatal Circumcision	MCUP3121
New Member Needs Assessment	MCUP2023
Health Information Form	MCUP2023-A
Health Risk Assessment Form	MCUP2023-B
Pediatric Health Risk Assessment Form	MCUP2023-C
Orthotic and Prosthetic Appliances Guidelines	MCUG3032
Osteopathic Manipulation Therapy	MCUP3130
Pain Management Specialty Services	MCUP3049
Medical Necessity Criteria for Pain Management Procedures	MCUP3049-A
Palliative Care: Intensive Program	MCUP3137
Palliative Care Eligibility Assessment	MCUP3137-A
Certification of Terminal Illness	MCUP3137-B
Engagement and Intensive Home-Based Palliative Care Enrollment Process	MCUP3137-C
Application to be a Contracted Intensive Home-Based Palliative Care Provider	MCUP3137-D
Palliative Care: Pediatric Program for Members Under the Age of 21	MCUP3140
Outpatient Pediatric Palliative Care Eligibility Assessment	MCUP3140-A
Engagement & Enrollment Process for Outpatient Palliative Care	MCUP3140-B
Application to be a Contracted Outpatient Palliative Care Provider	MCUP3140-C
PCP-To-PCP Transfers & Assignments of New Members to PCP	MCUP3034
Physical, Occupational and Speech Therapies	MCUP3114
Podiatry Services	MPUP3129
Positron Emission Tomography Scans (PET Scans)	MPUP3116
Prenatal & Perinatal Care	MCUG3118
PHPS Application and Update Form and Contracted Provider Addendum	MCUG3118-A
TAR Requirements for PHPS	MCUG3118-B
Applying for the CPSP Program	MCUG3118-C
Preoperative Day Review	MPUP3035
Pulmonary Rehabilitation	MCUP3111
Pulmonary Rehabilitation Questionnaire	MCUP3111-A
Referral to Specialists (RAF) Policy	MCUP3124
Rehabilitation Guidelines for Acute and Skilled Nursing Inpatient Services	MCUP3003
Residential Substance Use Disorder Treatment Authorization	MCUP3144
Review Guidelines for Member Placement in Long Term Care (LTC) Facilities	MCUG3038
Bed Hold & Change of Status Report Form	MCUG3038-A
Second Medical Opinions	MPUP3078
Screening and Treatment for Substance Use Disorders (previously Alcohol & Substance Abuse Screening & Treatment)	MCUP3101
Alcohol Misuse Screening & Counseling (AMSC) Training Resources	MCUP3101-A
Pocket Screening and Brief Intervention for Alcohol Use Disorders	MCUP3101-B
Application to be a Contracted Brief Intervention / Referral to Treatment Provider	MCUP3101-C
Review Documentation for Application to Become a Contracted Behavioral Counseling Intervention / Referral to Treatment Provider	MCUP3101-D
Youth Pocket Screening and Brief Intervention for Alcohol Use Disorders	MCUP3101-E
Sterilization Consent Protocol	MCUP3119
Street Medicine	MCUP3146
Technology Assessment	MCUP3042
Review of New Medical Technology Form	MCUP3042-A
Telehealth Services	MCUP3113
Transplant Authorization Process	MCUP3104
Treatment Authorization Request (TAR) Review Process	MCUP3041
TAR Requirements	MCUP3041-A
Tuberculosis Related Treatment	MCUP3047
TB Screening Guidelines (Flowcharts)	MCUP3047-A
Urgent Care Services	MCUP3044
Utilization Review Guidelines ICF/DD, ICF/DD-H, ICF/DD-N Facilities	MCUG3058
Bed Hold/TAR Process	MCUG3058-A
Vision Care	MCUP3102
Waiver Programs	MCUP3106
Wheelchair Mobility, Seating & Positional Components	MCUP3133

Please Direct Questions To:

Partnership HealthPlan of California
4665 Business Center Drive
Fairfield, CA 94534
Phone: (707) 863-4100

Section 5: Utilization Management

​​​Table of Contents - Medi-Cal

​CCS NL 06-1120Authorization of Insulin Infusion Pumps – Revised 11/17/2022

​​​Mifepristone Patient Agreement Form - Danco

​New Member Needs Assessment

​Health Information Form

​MCUP2023-A

​Health Risk Assessment Form

​MCUP2023-B

​Pediatric Health Risk Assessment Form

​​​​MPUP3078​​​

Table of Contents - Medi-Cal

CCS NL 06-1120Authorization of Insulin Infusion Pumps – Revised 11/17/2022

Mifepristone Patient Agreement Form - Danco

New Member Needs Assessment

Health Information Form

MCUP2023-A

Health Risk Assessment Form

MCUP2023-B

Pediatric Health Risk Assessment Form

MPUP3078