Michael E. McManus, M.D., Utilization Management Director

PCSD is a major force in the managed care field. PCSD has a commitment to the highest level of care and our wide geographic distribution, currently with 10 offices in San Diego County, has allowed us to have PCSD numerous managed care contracts with many of the major medical groups.

PCSD has established a comprehensive in-house program of quality assurance and utilization management.

PCSD fully complies with the National Committee for Quality Assurance (NCQA) written guidelines.

PCSD’s Utilization Management Program covers the following: Procedures to evaluate access, triage, and referral; medical necessity, appropriateness, and efficiency of health care services, level of care and effectiveness, and processes to detect under-as well as over-utilization of services.

To view the entire UM Plan, click here: UM PLAN

Data sources and Medical Necessity/Utilization Review Criteria used in decision-making.

Review, revise, adopt, Clinical Practice Guidelines annually with input from PCSD’s clinicians

Ensure distribution and implementation of the Clinical Practice Guidelines to PCSD’s clinicians

The process of conducting appeals of adverse Utilization Review determinations

Mechanisms to ensure consistent application of review criteria and compatible decisions

Provisions for assuring confidentiality of clinical information

The processes in place to periodically assess Utilization Review activities

The staff position functionally responsible for day-to-day Program management

Processes in place to review all requests for new Clinical Technologies and new application of existing Clinical Technologies

If you need assistance with:

  • Inpatient care
  • Partial hospital care
  • Intensive outpatient care
  • Sub-specialty care
  • How to obtain care or coverage for out of area
  • Or, how to appeal an UM decision

Please contact the UM Department at 619-528-4600 extension 6110.

If you have a question regarding the processing of your claim, please contact 619-528-4600 ext. 6449 for assistance.

Affirmative Statement

PCSD clinicians do not receive incentives nor do they have knowledge of incentives being given to reward inappropriate restriction of care.

UM decision making is based only on appropriateness of care and service and existence of coverage.

PCSD does not specifically reward practitioners or other individuals for issuing denials of coverage or service care.

Financial incentives for UM decision makers do not encourage decisions that result in under utilization.

FREQUENTLY ASKED QUESTIONS (FAQ)

What is a Co-payment?

A co-payment is a patient cost share. Co-payments are determined by the insurance carrier and are paid at the time of service.

What is a Cost-Share?

A cost-share is the amount for which the patient is responsible after the insurance company processes the insurance claim. The cost-share includes co-insurance responsibility and deductibles.

What is a carve-out?

Mental health benefits are sometime administered by behavioral health management companies and not the medical insurance company. The carve-out management organization will provide the patient with a referral to a network provider and authorize their treatment. PCSD clinicians are affiliated with many of these behavioral health organizations.

Do I need to obtain a referral to see a psychiatrist or therapist?

Yes, if your insurance is through an HMO or a managed care organization, mental health services need to be authorized by the insurance company or your primary care physician.  If you are referred directly by your insurance company, you may or may not need a referral or authorization.  It is always best to check with your insurance carrier.

How do I obtain a referral?

You may obtain a referral during a visit with your primary care physician OR you may call your insurance plan directly at the phone number they have provided you for this purpose.  You can then call PCSD at (619) 528-4600 to make the actual appointment.

Will my referral be mailed directly to PCSD?

Yes, your referral will be mailed directly to PCSD, however, you will also receive a copy.  It is important to bring any information your insurance company sends with you to your appointment at PCSD.

What are the hours for the Managed Care Department?

PCSD’s regular business hours for Administration and Billing are Monday through Friday, 8:00 a.m. to 5:00 p.m.

Is there a time limit on my referral?

Referrals and authorizations have time limits determined by the insurance company.  Most referrals are valid for 60 to 90 days.  This information will be shown on the referral you receive.

FORMS

Initial Authorization Form Instructions 

Initial Authorization Form

Concurrent Review Authorization Form