Decision to approve or deny a service is based only on appropriateness of care, service, and existence of coverage. NEMS does not reward practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for decision makers do not encourage decisions that result in underutilization.

NEMS UM staff are available to members and providers during regular business hours (Monday through Friday, 8:00am – 5:30pm) by calling 1 (415) 352-5186, Option 1. To discuss UM issues and denial decisions, or to request a copy of the policies, procedures, and UM criteria, please call 1(415) 352-5186, Option 1. Individuals with hearing or speech impairments may dial 1(800) 735-2929 for TTY services. NEMS provides language assistance for members whose primary language is not English. After normal business hours, UM staff can receive secure voicemail and fax. Our fax number is 1(415) 398-2895. Messages received are returned within one (1) business day. Our staff identifies by name, title, and organization name when initiating or returning calls regarding UM issues.

NEMS MSO uses the Medi-Cal criteria, Medicare criteria, Health Plan’s criteria, and MCG guidelines to guide utilization management decisions. This may include but is not limited to decisions involving prior authorization, inpatient review, level of care, discharge planning and retrospective review. Members and providers may request a copy of the policies, procedures, and criteria used to make a determination for a specific procedure or condition by contacting NEMS UM at 1(415) 352-5186, option 1.

Medi-Cal Criteria: https://medi-cal.ca.gov/

Medicare Criteria: https://www.cms.gov/medicare-coverage-database/new-search/search.aspx

NEMS MSO approves, adopts, and distributes evidence-based clinical practice guidelines from recognized sources and promotes them to providers and members in an effort to improve health care quality and reduce unnecessary variation in care.

Useful Guidelines and Resources

For treatment authorization requests, please visit our Prior Authorizations page linked here.