We understand your special needs. If you have complex medical or behavioral health needs, we offer Care Management services that are member-centered, family-focused and culturally competent. Our Care Managers are registered nurses or social workers. They can help you:
- Better understand and manage your health condition.
- Coordinate services.
- Locate community resources.
A Care Manager will work with you and your doctor to help you get the care you need. And if you have a severe medical condition, our Care Managers will work with you, your PCP and managing providers to develop a plan of care that meets your needs and your caregiver’s needs.
We do not reward practitioners, providers or employees who perform utilization reviews or issue denials of coverage or care. Utilization management (UM) decision-making is based only on appropriateness of care, service and existence of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization. Denials are based on lack of medical necessity or lack of covered benefit. Utilization review criteria have been developed to cover medical and surgical admissions. During the Utilization Review (UM) process all staff are identified by name, title & organization when initiating or returning calls regarding the UM process.