Utilization Management Practices: 
Authorization and Referrals 

For questions please call
the UM Department

Telephone:   (510) 428-3489
Fax:               (510) 450-5868

CFMG will accept collect calls
For TTY Users: (800) 855-7100

CFMG's Business Hours:
   Mon-Fri  --  8:00 am to 5:00 pm.

Utilization Criteria/Independent Utilization Management Decision Making
  • Children First Medical Group, Inc. uses standardized criteria from Milliman Care Guidelines (MCG) and Anthem Blue Cross criteria when making Utilization Management decisions. CFMG will provide copies of criteria to providers upon request via FAX or mail.

  • Utilization management (UM) decision making is based only on appropriateness of care and service and existence of coverage. The organization does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.

  • ​Practitioners are ensured independence and impartiality in making referral decisions that will not influence:​

    • Hiring ​

    • Compensation 

    • Termination 

    • Promotion 

    • Any other similar matters 

** In accordance to 29 CFR 2590.715-2719 (b)(2)9ii)(D).

For questions please call the UM Department

Telephone:   (510) 428-3489
Fax:               (510) 450-5868

CFMG will accept collect calls
For TTY Users: (800) 855-7100

CFMG's Business Hours:
 Mon-Fri  --  8:00 am to 5:00 pm.

UM FREQUENTLY ASKED QUESTIONS

WHAT IS THE STATUS OF MY AUTHORIZATION REQUEST?


As a reminder, routine requests are processed within 5 working days; urgent requests within 72 hours, and post-service requests within 30 calendar days. If your request is within these time frames, please be patient.




DO REHABILITATION SERVICES REQUIRE AUTHORIZATION?


Authorization is not required for the initial evaluation at UCSF Benioff Children’s Hospital Oakland or UCSF Benioff Children’s San Francisco. You may use the CFMG Specialty Referral Form to request an evaluation. Additional visits are requested by the treating therapist directly to CFMG.




HOW DO I REQUEST FORMULA FOR OUR PATIENTS?


Fax the physician order to the vendor. The vendor will then request authorization.




HOW DO I REQUEST A NEBULIZER FOR OUR PATIENTS?


Fax the physician order to CFMG at (510) 450-5868 or to the vendor.




HOW DO I REQUEST A DATE EXTENSION FOR AN AUTHORIZATION?


Fax the authorization letter with your requested extension date to (510) 450-5868.




WHERE DO WE REFER MEMBERS WHO CANNOT BE SEEN AT UCSF BENIOFF CHILDREN’S HOSPITAL OAKLAND DUE TO AGE?


Check the Health Plan website for a contracted provider, call the provider for availability, and submit the authorization request to CFMG.




HOW DO I GET A LISTING OF APPROVED CHILDREN FIRST MEDICAL GROUP (CFMG) SPECIALIST?


At www.childrenfirstmedicalgroup.org, in the left column, under MEMBERS - VISITORS, Click on Find a Physician and you can search by specialty, the doctor’s name or city.




HOW DO I FIND A LISTING OF CFMG OBSTETRICIAN/GYNECOLOGISTS?


Visit either health plans website: AlamedaAlliance.org or Anthem.com to find a physician. CFMG does not have OB/GYN’s in our network as OB services are Health Plan responsibilities.




DOES CFMG COVER PODIATRY?


Yes, Podiatry is a Health Plan benefit for Alameda Alliance for Health and Anthem Blue Cross, you will need to complete a CFMG Request for Authorization Form for visits. Refer to the Health Plan website for a listing of Podiatrists. CFMG does not have Podiatrists in our network.