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Medical
management

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.

 

Contact us

To learn more about medical management, check your provider manual (PDF). Or call us at 1-888-348-2922 (TTY: 711). We’re here for you 8:30 AM to 5 PM, Monday through Friday. 

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 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.

 

 

  • Pregnancy outreach
  • Special health care needs
  • Behavioral health and substance use

 

Members can self-refer for care management. Or you can refer them. Just call us at 1-888-348-2922 (TTY: 711).

 

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 use

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:

 

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. 

 

UM decision-making is based on:

 

  • Appropriateness of care
  • Service 
  • Existence of coverage

 

Adverse decisions

 

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. 

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.

 

You can also take a look at our member satisfaction results from recent years.

 

Member satisfaction results — 2022 (PDF)2021 (PDF) | 2020 (PDF)

 

We have a comprehensive ongoing Quality Assessment and Performance Improvement (QAPI) program that:

 

  • Focuses on the quality of clinical care and services to our members
  • Helps ensure that members get preventive health care in a timely manner 
  • Provides care management services to people with special health care needs 
  • Adheres to state and federal requirements 
  • Is overseen by the Governing Board of Directors and Quality Oversight Committees  

 

Performance improvement and measurement are fundamental to the QAPI 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 call us at 1-888-348-2922 (TTY: 711).

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

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