Utilization Management

We manage a comprehensive prior authorization process for specific services to verify medical necessity before treatment is delivered. Providers can conveniently submit requests through our secure Provider Portal or via fax in urgent cases. Each affiliated Independent Physician Association (IPA) has dedicated fax numbers and portal links to streamline communication.

We offer comprehensive support for new providers and office teams through orientation and training, scheduled in-person visits, and virtual check-ins. Ongoing assistance is available for claims, eligibility, reimbursements, and compliance, along with resources to support HEDIS, STAR measures, and other quality improvement initiatives.

All UM determinations at Guidant MSO are made using evidence-based criteria and the terms of the member’s health plan. Our team ensures that reviews are conducted without influence from financial incentives. Providers and members can request a copy of the criteria used in a decision, and we respond within one business day.

Members, providers, and other stakeholders are welcome to request the specific clinical guidelines or criteria that informed a decision. These guidelines are based on nationally recognized, evidence-based medical standards and are applied consistently across all reviews.

Requests for this information can be submitted through our Provider Portal, by phone, or by fax.

As part of our utilization management efforts in healthcare, we are committed to ensuring timely review and processing of all authorization requests. Standard requests are completed within 14 calendar days, while expedited (urgent) requests—when a delay could seriously jeopardize a patient’s health—are reviewed within 72 hours. This approach helps support appropriate, efficient, and timely access to necessary medical services.