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Our care management department provides support to members based on each individual’s risks and needs. These care needs are assessed by licensed nurses, social workers and counselors, as well as nonclinical professionals. We use a biopsychosocial (BPS) model to help us identify what care our members need. Then, the integrated case manager performs a health risk assessment to determine the member’s medical, behavioral health and BPS status.
Care managers work with members, their families, primary care physicians (PCPs), psychiatrists, substance abuse counselors or any other health care team members to achieve an efficient and cost-effective care plan. Care management teaches members about their specific diseases and how to prevent symptoms from getting worse. Our goal is to maintain or improve our members’ health.
Our care management programs include:
Pregnancy outreach and high-risk obstetrics
Special health care needs
Behavioral health and substance abuse
Our disease management program helps members manage specific conditions. We assist with:
Targeted outreach and support
The conditions in our program include:
Sickle cell anemia
HIV and AIDS
We are dedicated to providing high-quality care for our members. To do this, we monitor and evaluate our performance on a regular basis. This is the responsibility of our Quality Management (QM) department. QM is always making sure we’re doing the right thing for the right reasons.
We follow Maryland HealthChoice’s rules when we make our health care decisions. There are no rewards or financial incentives for our providers or staff for denying or reducing members’ benefits. You can submit your prior authorization claims with Eviti® Connect or evicore healthcare®.
We use Eviti Connect, a NantHealth® online platform, for utilization management services and oncological care. Our providers use Eviti Connect to validate cancer treatment and supportive medications that require prior authorization. Treatment plans are available on the Eviti Payer dashboard. You can find training and support on the Eviti Connect website.
You can learn more about Eviti Connect by:
We use eviCore healthcare for utilization management services for the following programs:
Musculoskeletal (pain management)
Radiology management (includes advanced imaging such as CT, MRI, MRA, PET scans)
Cardiology (cardiac imaging)
You can contact eviCore by:
- Calling them at 1-888-693-3211 (TTY: 711)
- Faxing them at 1-844-822-3862
- Visiting eviCore healthcare online