HOW YOUR PLAN WORKS Sample Clauses

HOW YOUR PLAN WORKS. A. Care Management and Medical Management (Utilization Review) Community Health Options® (“Health Options”) is committed to ensuring Members receive high-quality, medically appropriate care. An important part of the Plan is our medical management services. Our medical management team performs utilization review of health services to ensure they are Medically Necessary, evidence-based and delivered in the most effective health care setting. If you are hospitalized, have complex or serious health conditions, or are transitioning from one health care facility to another, our team will review your situation and determine whether you may benefit from care management services. These services are provided to you at no additional Out-of-Pocket Cost. When you are hospitalized, our Medical Management team will monitor your care to ensure you receive high-quality services that are most appropriate for your condition. We will also work closely with the Hospital staff to help plan your discharge from the Hospital to help make it a smooth transition and provide you with access to the health care services that are most appropriate for your condition. Our clinical specialists and clinical navigators work closely with your Primary Care Provider and local care management teams to coordinate your care. Our clinical specialists and clinical navigators can coordinate your Specialist appointments and help you obtain prescribed care such as Durable Medical Equipment, medical supplies, or Prescription medications. Health Options applies objective and evidence-based criteria and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. Under extraordinary circumstances that involve complex care or care management services the Plan may provide Benefits for services that are not listed in the “Covered Services” section 4.B. The Plan may also continue Covered Services beyond the contractual Benefit limit of this Agreement. These decisions are made on an individual basis and a decision to provide alternate services or continue Benefits is not precedent setting, and it does not obligate us to continue to provide those Benefits to you or any other Member in the future. We reserve the right, at any time, to change or stop providing alternate service Benefits or extended Benefits. Should we decide to change or stop your alternate services, we will notify you of that decision in writing. Members, their ca...

HOW YOUR PLAN WORKS. A. Care Management and Medical Management (Utilization Review) Community Health Options ® - quality, medically appropriate care. An important pa rt of the Plan is our medical management services. Our medical management team performs utilization review of health services to ensure they are Medically Necessary, evidence - based and delivered in the most effective health care setting. If you are hospi talized, have complex or serious health conditions, or are transitioning from one health care facility to another, our team will review your situation and determine whether you may benefit from care management services. These services are provided to you a t no additional Out - of - Pocket Cost. When you are hospitalized, our Medical Management team will monitor your care to ensure you receive high - quality services that are most appropriate for your condition. We will also work closely with the Hospital staff to help plan your discharge from the Hospital to help make it a smooth transition and provide you with access to the health care services that are most appropriate for your condition. Our clinical specialists and clinical navigators work closely with your Primary Care Provider and local care management teams to coordinate your care. Our clinical specialists and clinical navigators can coordinate your Specialist appointments and help you obtain prescribed care such as Durable Medical Equipment, medical supp lies, or Prescription medications. Health Options applies objective and evidence - based criteria and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. Under extrao rdinary circumstances that involve complex care or care management services the Plan may provide Covered Services beyond the contractual Benefit li mit of this Agreement. These decisions are made on an individual basis and a decision to provide alternate services or continue Benefits is not precedent setting, and it does not obligate us to continue to provide those Benefits to you or any other Member in the future. We reserve the right, at any time, to change or stop providing alternate service Benefits or extended Benefits.