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The goal of our care management program is to improve access to quality care and avoid unnecessary medical costs. We try to help with the efficient use of medical resources for members with special health care needs, including complex, chronic and catastrophic cases. The program is voluntary, and we provide these services once the member agrees to take part.
We identify members who might benefit from care management through:
- Utilization management activities
- Health risk assessments
- Screening of administrative data
Our care management team supports members based on their personal health risks and unmet needs. A case manager is assigned to each member. They’re part of the medical management team. And their job is to make sure members get all the care and services they need.
First, members are assessed by our licensed nurses, social workers, counselors or nonclinical professionals. Then, we use a biopsychosocial model to identify what care members need. Finally, the integrated case manager will do a health risk assessment. This determines the member’s medical, behavioral health and biopsychosocial status.
The disease management program helps with regular communications, targeted outreach and focused education. We help members with specific complex conditions, like asthma and diabetes.
Members get education, coaching and other services to help them manage their condition. They also receive help from disease management nurses. These nurses perform or facilitate health risk assessments. They can also create an action plan based on the member’s:
- Understanding of their condition
- Need for equipment and supplies
- Referral for specialty care or other special considerations due to comorbidities, including behavioral health and substance use
Utilization management (UM)
Utilization management (UM)
The purpose of UM is to review eligibility for benefits for the care that has been or will be provided to patients. The UM department is composed of:
Medical necessity is based on clinical standards and guidelines as well as clinical judgment. All clinical standards and guidelines used in the UM program have been reviewed and approved by practicing, participating physicians in our network.
Need a copy of our clinical standards and guidelines? Just call us at 1-800-441-5501 (TTY: 711), 7:30 AM to 7 PM, Monday through Friday.
The medical director makes all final decisions regarding the denial of coverage for services when the services are reviewed via our UM program. The provider is advised that the decision is a payment decision and not a denial of care. The responsibility for treatment remains with the attending physicians.
The policy on payment for services helps ensure that the UM decision-making process is based on consistent application of appropriate criteria and policies rather than financial incentives.
UM decision-making is based on:
Appropriateness of care
Existence of coverage
The medical director is available to discuss denials with attending physicians and other providers during the decision process. Notification of the decision includes:
The criteria used and the clinical reason(s) for the adverse decision
Instructions on how to request reconsideration
A contact person’s name, address and telephone number for requesting reconsideration
We do not reward practitioners, providers or employees who perform utilization reviews, including those of the delegated entities, for issuing denials of coverage or care. The compensation that we pay to practitioners, providers and staff assisting in utilization-related decisions does not encourage decisions that result in underutilization or barriers to care or service.
Want to learn more? You can contact our UM staff if you need help or have any questions related to a specific case. You can get help 8 AM to 7 PM, Monday through Friday.
Medicaid Managed Medical Assistance: Call 1-800-441-5501 (TTY: 711)
For questions after hours or during weekends or holidays, just leave a voicemail or fax. We’ll return your message.
Quality management (QM)
Quality management (QM)
The main goal of this program is to improve the health status of members. Our QM program uses multiple organizational components, committees and performance improvement activities to find opportunities for success. This allows us to:
- Assess current practices in both clinical and nonclinical areas
- Identify areas for improvement
- Select the most effective interventions
- Evaluate and measure the success of implemented interventions, refining them as necessary
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a widely used performance improvement tool. Visit our HEDIS page for more information.
Our Quality Improvement (QI) program helps us to make sure that our services meet high standards for safety and quality. We look at ways to better members’:
Access to doctors
We also always look for ways to make our services better. We do that by:
Measuring the quality and effectiveness of care and services
Making sure we use the best ways to check our services
Having qualified, competent and knowledgeable staff
Focusing on important problem areas
Being aware of our members’ culture and language needs
Making sure that we meet state and federal laws
Meeting all requirements of health care accreditation
Making sure we have a good network of doctors and hospitals
Making sure doctors and staff keep member information private
Performance improvement and measurement are fundamental to the QI program. We can’t improve what we don’t measure. So we analyze encounter data to identify gaps in care and recommend opportunities for improvement. Your involvement, feedback and recommendations for improving the delivery of care and services are welcome. Just contact us.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).