Utilization Management

Referrals to Specialists 

To see a Specialist or another provider, you usually need a referral from your Primary Care Physician and prior authorization from either your Medical Group or SHP. If you do not get the required referral and prior authorization and you get the service or treatment, you will have to pay all of the cost. For a list of services that do not require referrals, please refer to the Evidence of Coverage and Disclosure Form.

Standing Referrals 

If you have certain life-threatening, degenerative or disabling condition or disease requiring specialized medical care over a prolonged period of time, including HIV or AIDS, you may be provided with a standing referral. A standing referral is a referral for more than one visit, to a Specialist or “specialty care center” that has demonstrated expertise in treating a medical condition or disease involving a complicated treatment regimen that requires on-going monitoring. Those Specialists designated as having expertise in treating HIV or AIDS are designated in our Provider Directory under their licensed specialty with an asterisk.

Prior Authorization

Certain health care services require Prior Authorization by your Medical Group or SHP in order to be covered.  For additional information regarding services that require prior authorization, please call 1 (844) 805-8700. 

Your Primary Care Physician must contact SHP or in some cases, the participating Medical Group with which your Primary Care Physician is affiliated, to request the service or supply be approved for coverage before it is rendered. Certain Mental Health, Behavioral Health or Substance Use Disorder Treatment Services require Prior Authorization by Windstone in order to be covered. For Mental Health, Behavioral Health or Substance Use Disorder Treatment Services, the Windstone Participating Provider must contact Windstone for Prior Authorization. If Prior Authorization is not obtained when required, you may be liable for the payment of services or supplies. Requests for Prior Authorization will be denied if the requested services are not Medically Necessary as determined by SHP or the Medical Group or Windstone, as applicable.

Authorization, Modification and Denial of Health Care Services

Seaside Health Plan (SHP) uses established Utilization Mangement (UM) criteria to approve, deny, delay or modify authoriztion of benefits based on medical necessity.  The criteria used for evaluating requested health care services are based on generally accepted and professionally recognized standards of medical practice.  For medical health care services, SHP and its contracted Medical Groups utilize the UM criteria application hierarchy as follows:

  1. Federal or State Mandate;
  2. Health Plan Medical Policy or Clinical Guideline;
  3. Standardized Criteria (Milliman or InterQual);
  4. Standardized Behavioral Health Criteria (DSM-IV or VI-TR);
  5. Provider Group Criteria or Guideline;
  6. Community Resources (peer reviewed journals or published resources);
  7. If none apply, professional judgment is used.

Grievance Process

You can file a grievance for any issue. Your grievance must explain your issue, such as the reasons why you believe a decision was in error or why you are dissatisfied about Covered Services you received. Grievances may be submitted online, in writing or by telephone. You must submit your grievance within 180 days of the date of the incident that caused your dissatisfaction. For additional details on how to file a grievance, please visit GRIEVANCE FORM.

Continuity of Care

If your current healthcare provider is leaving the Seaside Health Plan network, you may be eligible for continuity of care if you have certain qualifying conditions. Please refer to the Continuity of Care Program policies and if you qualify, you may submit a completed application. Please visit Forms and Documents to download the Continuity of Care policies and application.

Independent Medical Review

Please visit Forms and Documents to download an Independent Medical Review form.

You Can Apply for an IMR if your Health Plan:

  • Denies, changes, or delays a service or treatment because the plan determines it is not medically necessary
  • Will not cover an experimental or investigational treatment for a serious medical condition
  • Will not pay for emergency or urgent medical services that you have already received

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (844) 805-8700 (TTY/TDD: 711) and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1 (888) HMO-2219) and a TTY/TDD line (711) for the hearing and speech impaired. The department’s Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.