Care Management. The Contractor’s protocol for referring members to care management shall be reviewed by OMPP and shall be based on identification through the health needs screening or when the claims history suggests need for intervention. In addition to population-based disease management educational materials and reminders, these members should receive more intensive services. Members with newly diagnosed conditions, increasing health services or emergency services utilization, evidence of pharmacy non-compliance for chronic conditions and identification of special health care needs should be strongly considered for case management. Care management services include direct consumer contacts in order to assist members with scheduling, location of specialists and specialty services, transportation needs, 24-Hour Nurse Line, general preventive (e.g. mammography) and disease specific reminders (e.g. Xxx X0X), pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency services. The Contractor shall make every effort to contact members in care management telephonically. Materials should also be delivered through postal and electronic direct-to-consumer contacts, as well as web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth grade reading level. All members with the conditions of interest shall receive materials no less than quarterly. The Contractor shall document the number of persons with conditions of interest, outbound telephone calls, telephone contacts, category of intervention, intervention delivered, mailings and website hits. Care management shall be coordinated with the Right Choices Program for members qualifying for the Right Choices Program. However, the Right Choices Program is not a replacement for care management.
Care Management. A set of Member-centered, goal-oriented, culturally relevant, and logical steps to assure that a Member receives needed services in a supportive, effective, efficient, timely, and cost-effective manner. Care Management is also referred to as Care Coordination.
Care Management. Functions of the MCO should support and enhance member-centered care. Designing member- centered plans that effectively and efficiently identify the personal experience outcomes and meet the needs and support the long term care outcomes of members and monitor the health, safety, and well-being of members are the primary functions of care management. Member- centered planning supports: 1) the success of each individual member in maintaining health, independence and quality of life; 2) the success of the MCO in meeting the long-term care needs and supporting member outcomes while maintaining the financial health of the organization; and
Care Management. Care management means a set of person-centered, goal-oriented, culturally relevant and logical steps to assure that a member receives needed services in a supportive, effective, efficient, timely and cost-effective manner. Care management emphasizes prevention, continuity of care and coordination of care, which advocates for, and links members to services as necessary across providers and settings. Care Management is provided to high risk populations such as but not limited to, individuals with HIV/AIDS, mental illness, addiction issues or those recently discharged from correctional institutions. At a minimum, care management functions must include, but are not limited to: (1) Health Risk Assessment for all members; (2) Short term care coordination, where appropriate; and, (3) Intensive Care Management, when appropriate. Care Management is provided by a Program Coordinator or Care Manager who is properly licensed by the State.
Care Management. Care Management services work to help ensure that you receive appropriate and cost-effective medical care. Your role in the Care Management process is simple, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you to call Customer Service to verify that you meet the required criteria for claims payment and to help us identify admissions that might benefit from case management. Your coverage for some services depends on whether the service is approved before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary and eligible for coverage under this plan. We will let you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required: Before you receive certain medical services and drugs, or prescription drugs Before you schedule a planned admission to certain inpatient facilities When you want to receive benefits for services from an out-of-network provider The plan has a specific list of services that must have prior authorization with any provider. The list is on our website at xxxxxxxxxx.xxx. Before you receive services, we suggest that you review the list of services requiring prior authorization. LifeWise Connect providers will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services. Generally this plan does not cover services from providers not in the LifeWise Connect network. If there is not a LifeWise Connect provider that can provide the service needed, see Services from Out-of-Network Providers for more information. We will respond to a request for prior authorization within 5 calendar days of receipt of all information necessary to make a decision. If your situation is clinically urgent (meaning that your life or health would be put in serious jeopardy if you did not receive treatment right away), you may request an expedited review. Expedited reviews are responded to as soon as possible, but no later than 48 hours after we get the all information necessary to make a decision. We will provide our decision in writing. Our prior authorizations will be vali...
Care Management. Care Management services work to help ensure that you receive appropriate and cost-effective medical care. Your role in the Care Management process is simple, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you to call Customer Service to verify that you meet the required criteria for claims payment and to help us identify admissions that might benefit from case management. Your coverage for some services depends on whether the service is approved before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary and eligible for coverage under this plan. We will let you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required: Before you receive certain medical services and drugs, or prescription drugs Before you schedule a planned admission to certain inpatient facilities When you want to receive the higher benefit level for services you receive from an out-of-network provider
Care Management. HMHP may contract with Payors for HMHP to administer care management, utilization management and quality assurance programs for Payors. The Parties acknowledge and agree that such Payor programs will solely cover such Payors’ respective Enrollees and that HMHP will use clinical data relating solely to those Enrollees for this purpose.
Care Management the provision of person-centered, coordinated activities to support Enrollees’ goals as described in Section 2.5.E of this Contract.
Care Management. The Contractor shall provide Care Management activities to appropriate Enrollees as described in this Section and further specified by EOHHS.
1. The Contractor shall proactively identify Enrollees who may benefit from Care Management activities based on the results of a systematic evaluation as described in this Section. Such evaluation shall:
a. Explicitly incorporate, at a minimum:
1) Enrollees with Special Health Care Needs;
2) Enrollees with LTSS needs as indicated by the results of the Care Needs Screening described in Section 2.3.B.2.g;
3) Enrollees who are identified by EOHHS as potentially in need of Care Management;
4) Enrollees who are identified by PCPs as potentially in need of Care Management; and
5) Enrollees who self-identify to the Contractor as potentially in need of Care Management;
b. Incorporate information contained, if applicable and as available, in each Enrollee’s:
1) Care Needs Screening;
2) Claims or encounter data;
3) Medical records;
4) Laboratory results;
5) Pharmacy data;
6) Discharge data; and
7) Other relevant sources of information identified by the Contractor or EOHHS; and
c. Incorporate predictive modeling of an Enrollee’s risk for high cost, high utilization, admission, re-admission, or other adverse health outcomes.
2. The Contractor shall provide each identified Enrollee with Care Management as follows:
a. Care Management shall include, but not be limited to, activities such as:
1) Providing a Comprehensive Assessment as described in Section 2.3.D.1
2) Otherwise comprehensively assessing Enrollee’s with Special Health Care needs as described in Section 2.3.D;
3) Creating a documented Care Plan as described in Section 2.3.
Care Management. The Contractor will offer Care Management services to all Enrollees as needed, and will develop, maintain, and monitor a care plan for all Enrollees to support health and wellness, ensure effective linkages and coordination between the PCP and other Health Care Professionals and providers and services, and to coordinate the full range of medical and behavioral health services, preventive services, medications, LTSS, social supports, Telemedicine services and enhanced benefits as needed, both within and outside the Contractor. Care Management services include ICM for community-based LTSS Enrollees and non-LTSS high-risk Enrollees. Care Management services also include care coordination services for individuals with more limited Care Management needs and transition coordination for Enrollees in nursing facilities who have an opportunity for discharge to the community. All Care Management services will be person-centered and will be delivered to Enrollees according to their strength-based needs and preferences. Enrollees will be encouraged to participate in decision making with respect to their care. If an Enrollee is unable to be reached after three attempts, or they choose not to participate, then a care plan is not required. At least annually, the Contractor shall attempt to reach Enrollees whom they were unable to reach or who chose to not participate in care planning and offer care management services and the development of a care plan. The Contractor shall have effective systems, policies, procedures and practices in place to identify Enrollees in need of Care Management services, including an early warning system and procedures that xxxxxx proactive identification of high-risk Enrollees and to further identify Enrollees’ emerging needs. A determination of which Enrollees are at high risk will be made by the Contractor as a result of either its predictive modeling results or a CFNA, as described in Section 2.6.2. Enrollees who are determined to be at high-risk and eligible for ICM may include, but not be limited to, individuals with complex medical conditions and/or social support needs that may lead to: the need for high-cost services; deterioration in health status; or institutionalization. The Contractor shall have effective systems, policies, procedures, and practices in place to identify Enrollees in need of Home Stabilization Services. The Contractor is required to coordinate with the out-of-plan Home Stabilization Service providers as part of the...
