Utilization Management

To contact Utilization Management (UM) staff regarding UM questions or a free copy of criteria used to make medical necessity decisions during the utilization review process, please call the following number: 1-888-936-PLAN (7526).

Please note Health Plan of San Joaquin / Mountain Valley Health Plan (“Health Plan”) does not require prior-authorization for post-stabilization members at a non-contracted facility. Please notify the plan within 24 hours of admission.

Prior Authorization may be requested by telephone to Utilization Management Department at 1-209-942-6350, fax to 1-209-762-4702 (San Joaquin County) or 1-209-762-4703 (Stanislaus County), mail or electronic submission

Staff are available to answer UM questions from 8:00 AM – 5:00 PM, Monday through Friday. Customer Services Representatives are available to answer general inquiries about UM issues such as the status of your request for approval of a service.

For more specific UM questions regarding detailed clinical information or discussion about specific UM, Customer Service Representatives will transfer you to speak directly with Medical Management staff.

Health Plan staff are also available outside of normal business hours. Health Plan staff can receive calls regarding UM issues before 8:00 AM and after 5:00 PM. Callers who need assistance after normal business hours may leave a message via a secure Customer Services voicemail line. All voicemail messages are retrieved each day at 8:00 am. Responses to voicemails are returned no later than the next business day.

For members with hearing or speech impairments, Health Plan provides Telecommunications Device for the Deaf (TDD) and/or Telephone Typewriter (TTY) services. Please contact: 1-209-942-6306. Health Plan also offers language assistance to discuss UM issues free of charge.

To our Network Practitioners and Providers:

Health Plan’s mission is to continuously improve the health of our community. Health Plan supports its mission through our vision statement, which is to provide health care value and advance wellness.
Our affirmation statement about Utilization Management Incentives is clearly understood by all Health Plan staff involved in UM-decision making as follows:

UM decision making is based only on appropriateness of care and services and existence of coverage.
Health Plan does not specifically reward practitioners or other individuals for issuing denials of coverage.
Financial incentives for UM decision makers do not encourage decisions that result in underutilization.

If you have any questions, please contact our Provider Services Department at 1-209-942-6340.