Getting Care

Utilization Management

To contact Utilization Management (UM) staff regarding UM questions, concerns, or issues, please call the following the number: 1-888-936-PLAN (7526). 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.

HPSJ staff are also available outside of normal business hours. HPSJ 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, HPSJ provides Telecommunications Device for the Deaf (TDD) and/or Telephone Typewriter (TTY) services. Please contact: (209) 942-6306. HPSJ also offers language assistance to discuss UM issues free of charge.

HPSJ’s UM policies does not allow financial incentives for utilization management decision-makers. UM decisions are based only on appropriateness of care and service and the existence of coverage. There are no rewards or incentives for doctors or other individuals for deny coverage, service, or care.

HPSJ’s specific UM criteria are made available for practitioner review on-site or via fax/email. UM criteria will be mailed or faxed to a practitioner/provider upon request. Practitioners/providers are notified in writing via the provider alert that the information is available.

Posted on June 16th, 2015 and last modified on July 29th, 2022.