Utilization Management

Please see below for details on utilization management and clinical resources for your patients. If you need additional assistance, please Contact Us.

Prior Authorization

Certain health care services require Prior Authorization by the Medical Group or SHP in order to be covered. Primary Care Physicians must contact SHP or in some cases, the participating Medical Group with which a 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, the member 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. Please contact SHP Member Services for additional information regarding services that require prior authorization.

Utilization Management Criteria

Seaside Health Plan adopts MCG (formerly Milliman Care Guidelines) including guidelines for:

  • Ambulatory Care
  • Home Care
  • Recovery Facility Care
  • General Recovery Care l Inpatient & Surgical Care l Chronic Care
  • Patient Information

Seaside Health Plan's recommendation of these guidelines is not an authorization, certification, explanation of benefits, or a contract. Benefits and eligibility are determined in accordance with the requirements set forth by the State of California

Drug Formulary

To view the prescription drug formulary, please visit the Prescription Drug List page.

Mental Health

The Seaside Health Plan offers access to Mental Health, Behavioral Health, and Substance Use Disorder Treatment Services through Windstone Behavioral Health Inc. (a specialty Independent Practice Association). Treatment Services are coordinated and administered by Windstone. Referrals are not needed from PCPs or from Windstone to see a Windstone Participating Provider for office visits for Mental Health, Behavioral Health Services, medication management or Substance Use Disorder treatment. Certain Mental Health, Behavioral Health and Substance Use Disorder services require prior authorization from Windstone.

Chiropractic and Acupuncture

Access to chiropractic and acupuncture services is offered through American Specialty Health (ASH). Treatment Services are coordinated and administered by ASH. American Specialty Health Incorporated and its subsidiaries are one of the nation’s premier independent and privately-owned specialty health services organizations, providing specialty health care networks and programs, fitness and exercise programs and population health solutions. Through its subsidiaries, ASH administers programs for nearly 34 million members and contracts with more than 32,000 health care practitioners and service providers. For specific benefits and coverage provided for these services, please refer to the Evidence of Coverage and Disclosure Form.

  • For information on chiropractic and acupuncture services, call ASH customer service toll free at (800) 678-9133 (TTY/TDD: 711) or email them at service@ashn.com. Member Service Hours are as follows:
    M-F: 4am - 8pm Pacific Time 
    Sat: 12pm - 8pm Pacific Time
  • Please visit ASH Participating Provider to search for a provider on line