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The goal of our medical management team is to promote cost-effective care that helps members be as healthy as they can be. This means working with providers to assess conditions, create care plans, coordinate resources and check progress.


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To learn more about medical management, check your provider manual (PDF). Or call us at 1-800-279-1878 (TTY: 711).

Care management

Care management

Our goal 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.


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 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. 


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.



  • High-risk pregnancy
  • Special health care needs
  • Behavioral health and substance use


Members can self-refer for care management. Or you can refer them. Just call us.


More about care management

Chronic disease management

Chronic disease management

The chronic disease management program helps with regular communications, targeted outreach and focused education. We help members with specific 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 abuse

More about chronic disease management

Utilization management (UM)

Utilization management (UM)

The purpose of UM is to manage the use of health care resources to ensure that members get the most medically appropriate and cost-effective health care. The goal? Improving medical and behavioral health outcomes.


The UM team will help providers:


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


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. No reviewing provider may perform a review on one of their patients, or cases in which the reviewing provider has a proprietary financial interest in the site providing care.


UM decision-making is based on:


  • Appropriateness of care
  • Service 
  • Existence of coverage

Want to learn more? You can contact our Health Services Department if you have any questions related to:


  • Inpatient authorizations
  • Concurrent reviews
  • Discharge planning
  • Case management
  • Prior authorizations


Call 1-800-279-1878. You can get help 24 hours a day, 7 days a week. For after-hours or weekend questions, just choose the prior authorization option to leave a voicemail. We’ll return your call.


More about prior authorization

All providers and members can access medical and behavioral health management criteria and practice guidelines if needed. You can ask for a free copy of individual guidelines for a specific case by phone. Just call us:


Medallion (Medicaid) and FAMIS: 1-800-279-1878

CCC Plus: 1-855-652-8249

Quality management (QM)

Quality management (QM)

Our Quality Management (QM) program is committed to providing a high standard of quality. Improving care and services for members is our main focus. We review our QM program every year to assess opportunities for improvement and the need for change. 


You can also help us understand where we need to improve our processes. Your satisfaction with us as your health plan is our goal. 


Here are some steps we take to help improve processes for our members: 


  • Providing education on prevention and wellness care through outreach for:
    • Well visits and dental visits
    • Lead screening
    • Immunizations for children and adolescents
    • Women’s health screenings, like mammograms and cervical cancer screenings
    • Pregnancy care
  • Surveying members and providers to measure satisfaction (CAHPS survey/provider satisfaction survey)
  • Working with members who have serious health issues through case management
  • Sharing information about health care costs with members
  • Measuring standards like how long it takes for a member to get an appointment
  • Monitoring phone calls to make sure your call is answered as quickly as possible and that you get correct information
  • Working with providers to help them provide members with the care they need
  • Reviewing calls and complaints from members and providers
  • Reviewing all aspects of the health plan through committees that include health plan staff, providers and members


Want more information about our improvement processes? Just call us to learn more.


The Healthcare Effectiveness Data and Information Set (HEDIS®) is a widely used performance improvement tool. Visit our HEDIS page for more information.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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