Home Member Services Care Management

Care Management

Care Management looks at a patient's risks, needs, and goals and then puts together an action plan to get to the outcome the patient wants.

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

• Case Management
• Disease Management
• Utilization Management
• Special Health Care Needs
• Member Review and Intervention Program (MRIP)

The Care Management team tries to:

• Be the patient's advocate.
• Coordinate services to the patient.
• Track how well the care plan is working to maintain the patient's health.
• Support the relationship between the patient and providers.

Community Health Plan can help to support high-risk moms during pregnancy or postpartum recovery. If you need this support, Case Management will keep in touch with you by phone during the pregnancy and the 6-week postpartum recovery. We also work with an in-home nursing service 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 Community Health Plan Care Management team uses clinical and evidence-based guidelines as tools in its process. Community Health Plan tests how well the care management process by using utilization management reviews and concurrent reviews. These reviews find and assess potential care coordination, disease management, and discharge needs. They also help to find patients who could be helped by case management.

Providers can access care management for patients in several ways:

• Prior authorization requests
• Customer service department alerts
• Case management referral
• Referral by the patient herself or himself

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

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.