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

• American Academy of Pediatrics Bright Futures Guidelines and Pocket Guide

• American Association for the Study of Liver Diseases

• American Diabetes Association: Clinical Practice Guidelines

• CDC Immunization Guidelines

• Hepatitis C Guidelines

• JNC7 Guidelines for Hypertension

• NIH Guidelines for the Diagnosis and Management of Asthma

• The American College of Obstetricians and Gynecologists (ACOG)

• U.S. Preventive Services Task Force

Terminally ill members, age 18 or older, with the capacity to make medical decisions are permitted to request and receive prescriptions for aid-in-dying medications if certain conditions are met.  Provision of these services by health care providers is voluntary and refusal to provide these services will not place any physician at risk for civil, criminal, or professional penalties. End of Life (EOL) Services include consultations and the prescription of an aid-in-dying drug.  EOL services are a “carve out” for Medi-Cal Managed Care Health Plans and are covered by Medi-Cal Fee-for-Service (FFS).  Members are responsible for finding a Medi-Cal FFS Physician for all aspects of the EOL benefit. NEMS policy & procedure describes:

1. During an unrelated visit with a NEMS Medical Group physician, a member may provide an oral request for EOL services. If the physician is also enrolled with the Department of Health Care Services (DHCS) as a Medi-Cal FFS provider, that physician may elect to become the members attending physician as he or she proceeds through the steps in obtaining EOL services.
2. EOL services following the initial visit are no longer the responsibility of NEMS Medical Group, and must be completed by a Medi-Cal FFS attending physician, or a Medi-Cal FFS consulting physician.
3. Alternatively, if NEMS Medical Group physician is not a Medi-Cal FFS provider, the physician may document the oral request in his or her medical records as part of the visit.
4. NEMS Medical Group physician should advise the member that, following the initial visit, he or she must select a Medi-Cal FFS physician in order for all of the remaining requirements to be satisfied.

Palliative care is patient- and family- centered care that improves quality of life by anticipating, preventing, and treating suffering. Palliative care does not require the member to have a life expectancy of six (6) months of less and may be provided at the same time as curative care.

Palliative care includes:

• Advanced care planning
• Palliative care assessment and consultation
• Plan of care with a physician, nurse, social worker, and/or chaplain
• Care coordination
• Pain and symptom management
• Mental health and medical social services

Adults who are age 21 or older cannot receive both palliative care and hospice care at the same time. If you are getting palliative care and meet the eligibility for hospice care, you can ask to change to hospice care at any time. Please contact your health plan for a referral to palliative care.