Care and Case Management

The Care Management Team at Community Health Plan is part of the Medical Management Department.

Care Management is a comprehensive method of client assessment—designed to identify client vulnerability, needs, and goals—that results in the development of an action plan to produce an outcome that is desirous for the client. The goal is to provide client advocacy, a system for coordinating client services, a systematic approach to evaluation of the effectiveness of the client's health maintenance, and most importantly, supporting the client-provider relationship.

Community Health Plan's Care Management Team utilizes clinical guidelines and evidence-based guidelines as tools to facilitate the care management process. Providers can access the Milliman Care Guidelines through the Care Management Portal at https://jiva.chpw.org. Community Health Plan’s Clinical Coverage Criteria can be accessed at this page. 

The care management process is monitored through utilization management review activities, concurrent review activities, which assess and identify potential care coordination, disease management, discharge needs and case management candidates. Providers can access care management for patients in several ways, through prior authorization requests, customer service department or through a case management referral.

New Arrivals

Community Health Plan offers a program for expectant mothers called New Arrivals. This is a free and voluntary program that is in addition to the care patients receive from their provider during pregnancy.

Community Health Plan also offers support for high-risk moms during pregnancy or postpartum recovery. If patients need this support, case management will keep in touch with them by phone during the pregnancy and the 6-week postpartum recovery.

We also work with an in-home nursing service, Alere, that can:

  • Help care for you if you have complications such as diabetes, pre-term labor, and hyperemesis.
  • Monitor high blood pressure related to your pregnancy.

The Care Management Team consists of clinical and nonclinical staff in the following areas:

Please click the link for each area to learn more about it.

If you would like to see additional topics discussed, please contact us.

Community Health Plan staff and providers approve or deny services. We use information from your doctor to do this. We also look at medical standards. We do not offer decision-makers money to decide either way. We do not stop using providers if they disagree with our decisions. Our decisions are fair and equal.

We follow these rules:

  • Utilization Management decision makers approve or deny based only on whether the care and service are appropriate and whether the care or service is covered.
  • Community Health Plan does not reward providers or others for denying coverage or care.
  • Community Health Plan does not offer financial incentives to encourage Utilization Management decision makers to make decisions that result in under-using care or services.

"Medically necessary" is a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally effective, more conservative, or substantially less costly course of treatment available or suitable for the client requesting the service. For the purpose of this section, "course of treatment" may include mere observation or, where appropriate, no treatment at all.

Staff are available to discuss the utilization management process.  An appropriate peer reviewer (Medical Director, Pharmacist, or Associate Clinical Director) is available to discuss any Utilization Management authorization, or denial.  The toll-free number to contact UM staff and peer reviewers is 1-800-440-1561. Relevant policies and/or clinical criteria are available upon request.