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Medical management

The goal of medical management is to ensure that members are getting medically necessary evidence-based care. This means working with providers to assess conditions, create care plans, coordinate resources and check progress.

Contact us

To learn more about medical management, check your provider manual (PDF). Or call us at 1-855-242-0802 (TTY: 711). 

Care management

Care management

Our care management team supports members based on their personal health risks and unmet needs. A care 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.


Have questions? You can contact the Care Management Team directly.




We use several sources to identify members for care management and disease management: 


  • Enrollment data from the state 
  • Predictive modeling tools 
  • Claim/encounter info, including pharmacy data, if available 
  • Data collected through the utilization management process 
  • Lab results 
  • Hospital or facility admissions and discharges
  • Health risk appraisal tools 
  • Data from health management, wellness or health coaching programs 
  • Provider referrals for members who act inappropriately or are disruptive or threatening in the office 

Once these members are identified, they are then assessed by our licensed: 


  • Nurses 
  • Social workers 
  • Counselors 
  • Nonclinical professionals 

Afterwards, we use a biopsychosocial model to identify what care members need. Finally, the care manager will do a health risk assessment. This determines the member’s medical, behavioral health and biopsychosocial status. 

We can help your patients with certain conditions enhance their self-management skills. This includes conditions like:


  • Asthma
  • Diabetes
  • Chronic obstructive pulmonary disease (COPD)
  • Hepatitis C
  • Other conditions

Care management programs may also include topics like:


  • Pregnancy outreach and high-risk obstetrics (OB)
  • Special health care needs 
  • Behavioral health and substance abuse


Care managers educate members about their condition and how to prevent worsening of their illness or any complications. The goal is to maintain, promote or improve their health status. 


To create a quality-focused, cost-effective care plan, care managers collaborate with:


  • The member
  • Member’s family
  • Primary care provider 
  • Psychiatrist
  • Substance abuse counselor
  • Other health care team members


To identify members that are the right fit for care management, we may use referrals from:


  • Our health info or special needs lines
  • Members
  • Caregivers
  • Providers
  • Practitioners 


Integrated care management means your patient only has one care manager, even if they also take part in:


  • Care management
  • Condition management


Learn more about care management

Our care managers can offer special attention to members who have a high-risk pregnancy. Members can get support for a healthier pregnancy, including info about preterm labor and birth.  


Do you have a patient who’s pregnant?

Be sure to complete and submit the notice of pregnancy form (PDF). This will help us to identify if your patient has a high-risk pregnancy. We’ll then connect them to the care and services they need. 


You can submit the form in one of two ways: 


  • Complete the form and fax it to: 1-866-776-2813, Attention: Care Management  
  • Call Provider Relations at 1-855-242-0802 (TTY: 711)  for help submitting the form

Utilization management (UM) 

The UM team helps providers:


  • Complete authorization requests submitted by phone, fax or Provider Portal 
  • Review clinical guidelines and requests for peer-to-peer reviews 
  • Identify discharge plans for members leaving a hospital or facility 

You can learn more about our UM criteria at these links.


BRCA 1 and 2 Gene Testing and Genetic Counseling Policy (PDF)


Continuous Positive Airway Pressure (CPAP) Policy (PDF)


Bariatric Surgery and Pannulectomy Policy (PDF)


CPT Vest-High Frequency Chest Policy (PDF)


Peer Support Services Policy (PDF)


Assertive Community Treatment (ACT) Services (PDF)


Substance Use Disorder Treatment- Intensive Outpatient and Residential Levels of Care (PDF)


Pediatric Day Health Care (PDF)


Crisis Stabilization Services for Adults (PDF)


ASAM Determination Grid (PDF)


ASAM Scroing Guide (PDF)


Applied Behavior Analysis (PDF)


Peer Support Services (PDF)


Community Brief Crisis Support (CBCS) and Behavioral Health Crisis Care (BHCC) (PDF)


Personal Care Services- Behavioral Health (PDF)


Crisis Intervention (CI) Services (PDF)


Multi-Systemic Therapy (MST) (PDF)


Community Psychiatric Support and Treatment (CPST) and Psyc (PDF)


Mental Health Intensive Outpatient (PDF)


Assertive Community Treatment (ACT) Services (PDF)


National Comprehensive Cancer Network


MCG Health authorization criteria provider search — general  


MCG Health authorization criteria provider search — specific criteria 


Medical clinical policy bulletins (CPB) search 


Clinical policy bulletins 


Provider manual (PDF)


Louisiana Department of Health (LDH) applied behavior analysis provider manual (PDF)


LDH behavioral health services provider manual (PDF)


LDH general provider manuals


Member handbook (PDF)


Member handbook for mental health and substance use treatment services (PDF)


Child and Adolescent Level of Care Utilization System (CALOCUS) — evaluation parameters (PDF)


CALOCUS — worksheet (PDF)


Level of Care Utilization System (LOCUS) — level of care determination grid (PDF)


LOCUS — scoring sheet (PDF)


LOCUS — Levels Care Handout (PDF)

We base our utilization management (UM) decisions on appropriateness of care and service, subject to covered benefits. If we contract with practitioners and providers to make UM decisions, we require that they make decisions based only on appropriateness of care and service. 


We don’t provide incentives or make financial arrangements that encourage staff or contracted providers making UM decisions to:


  • Issue denials, limitations or discontinuation of medically necessary care 
  • Make decisions that lead to underutilization  

This includes our policies and practices in: 


  • Hiring
  • Compensation
  • Termination
  • Promotion
  • Any similar matters

Quality management 

Quality management 

The main goal of this program is to improve the health status of members. Our quality management 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 
  • Choose the most effective interventions 
  • Evaluate and measure the success of implemented interventions, refining them as necessary 

Learn more about quality management


Learn more

Just download our provider manual (PDF) for more info about medical management.


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