Claim Regulations & Policies    
Annual Disclosure Letter AB1455 (APC)
Annual Disclosure Letter AB1455 (LSMA)

Claim Information, Policies and Procedures are available upon request to providers and members by calling our Customer Service department at (877) 282-8272 Opt. 1, Monday-Friday between 9:00 AM - 5:00 PM.
Financial Incentive Attestation   Download File
To ensure all members and providers receive quality care, Network Medical Managment does not offer any financial incentives to anyone for decision making. All decisions are made based on medical necessity. All UM decision making is based only on appropriateness of care and service and existence of coverage.
Quality Management Program & Policies   Download File
Network Medical Management's Quality Improvement Program is designed to promote the highest quality medical care and service to members of Network Medical Management and its affiliate IPAs. It is based on the ability to perform on-going evaluation and modification so as to stay effective in the dynamic health care environment. Program goals are achieved through the proactive identification and resolution of issues that directly or indirectly affect member care. The Quality Improvement Plan examines methods, processes and outcomes with emphasis on improvement initiatives.

The objectives of the program are guided by the goal of maintaining an integrated system that assures quality of care and service to all patients. This is accomplished by proactively identifying methods to continuously improve the quality of health care delivered. The program also recognizes the importance of member satisfaction and incorporates this aspect of quality improvement into the overall program goals.

The primary goals of the program are to improve member quality of life, control the cost of care and manage exposure to risk. These goals will be achieved by working with the health plans providers and community resources. The following objectives will direct the on-going development of the policies and procedures for the QI Program:

1. To increase the process of communication, feedback, education and continuous quality improvement.

2. To improve the quality of care and safety of clinical care provided to members by proactively identifying methods to continuously improve the quality of health care and service.

3. To evaluate the effectiveness of actions implemented to correct identified deficiencies.

The Quality Management guidelines are based on the National Committee for Quality Assurance, State Department of Health Services, and Department of Managed Health Care. All policies and procedures provide information primarily on Access to Care standards and Medical Office standards. These guidelines will assist physician’s offices in complying with state regulations and health plan standards.

Quality Management Program, Policies and Procedures are available upon request to members and providers by calling our Customer Service department at (877) 282-8272 Opt. 1, Monday-Friday between 9:00 am-5:00 pm.
Utilization Management Policies  
Note: There is no document associated with this area. Please review the following policy information.

Procedures and Criteria are disseminated to members upon request by calling our Customer Service department at (877) 282-8272 Opt.1, Monday through Friday between 9AM and 5PM.

Criteria Disclosure:
Procedures and Criteria are disseminated to members and provider upon request by calling our Customer Service department at (877) 282-8272 Opt.1, Monday through Friday between 9AM and 5PM. For the hearing impaired, please call our TTY telephone at 877-735-2929, Monday Through Friday between the hours of 8.30am to 5pm

A requesting practitioner may call Network Medical Management to discuss a denial, deferral, modification, or termination decision with the physician (or peer) reviewer at (877) 282-8272 ext.6195; Monday through Friday between the hours of 9.30am to 2.30 pm. All calls will be returned within 24 hours.

Disclosure Notice:
The materials provided to you are guidelines used by the medical group to authorize, modify or deny care for persons with very similar illnesses or conditions. Specific care and treatment may vary depending on individual need and benefits covered under your contract. Those are guidelines and do not constitute the standard of care.

  • Network Medical Management will disclose a list of contracting providers to members upon request.
  • Utilization Management medical clinical guidelines will be disclosed to members and practitioners upon request.
  • All Utilization Management decisions are based on appropriateness of care and service, and existence of coverage.
  • Network Medical Management does not compensate practitioners for individual denials.
  • Network Medical Management does not offer incentives to encourage denials.
  • Network Medical Management does not have the financial incentives that would encourage decisions that would impact under/over utilization of care, service or available member benefits. For questions or concerns that are Utilization Management related only, patients can telephone any of our local Referral Coordinators collect. Collect calls being accepted by the Utilization Management Department only for Utilization Management issues.
"The material provided to you are guidelines used by this plan to authorize, modify, or deny care for persons similar illnesses or condition. Specific care and treatment may vary depending on individual need and the benefits covered under your contract." Ref CA HSC 1361.5 ©