Common use of Emergency Room Utilization Program Clause in Contracts

Emergency Room Utilization Program. This program provides an integrated care management approach for Members who have had an emergency room (ER) visit and were not subsequently admitted to an acute inpatient facility. Members will receive an automated outbound telephone call to provide educational information related to available alternative care options. Alternative care options include Capital BlueCross’ Nurse Line, the Member’s primary care provider office, and Urgent Care Centers. The educational telephone call is not to discourage utilization of the ER, but to provide education on the use of alternative care options when appropriate. Members will be asked if they have a primary care provider. If they do not, assistance in locating either a primary care provider or an Urgent Care Center will be offered. The Capital BlueCross website and Customer Service telephone number also will be offered. Additional follow-up telephone calls along with more intensive assessments will be made to Members with multiple ER visits. Referrals to a care management program will be made where appropriate. DELEGATION OF UTILIZATION REVIEW ACTIVITIES AND CRITERIA Utilization Review and Criteria for Behavioral Health Services Utilization Review activities for behavioral health services (Mental Health and Substance Abuse services) have been delegated by the HMO to its contracted behavioral health management company which administers the behavioral health Benefits for the majority of the HMO's Members. Members seeking Mental Health care and Substance Abuse services may obtain Preauthorization for such services from the contracted behavioral health management company. DISEASE MANAGEMENT PROGRAMS The Disease Management Program is a collaborative program that assesses the health needs of Members with a chronic condition and provides education, counseling, and information designed to increase the Member’s self-management of this condition. The goals of Keystone Health Plan Central’s Disease Management Program are to maintain and improve the overall health status of Members with specific diseases through the provision of comprehensive education, monitoring and support for healthy self-management techniques. The Disease Management Program is especially beneficial for Members who have complex health care needs or who require additional assistance and support. Participation in Keystone Health Plan Central’s Disease Management Program is voluntary and involves no additional cost to our Members.