Care Coordinators. Each Enrollee identified as requiring Care Management, and any other Enrollee who agrees or wishes to receive Care Management, will be assigned a Care Coordinator. Contractor must provide Enrollee information on how to contact their designated person or entity primarily responsible for coordinating services.
Care Coordinators. Each Enrollee who receives Care Management will be assigned a Care Coordinator. Contractor must provide Enrollee information on how to contact the Enrollee’s designated person or entity primarily responsible for coordinating services.
Care Coordinators. The Plan shall utilize licensed personnel in medical professions to review requests for Prior Authorization and perform the duties of Care Coordinators. Such Care Coordinators shall have authority to perform Utilization Review per established scientific, evidence- based clinical criteria for the purpose of making a determination as to the Medical Necessity for services under the terms and provisions of the Member’s Benefit Agreement. Utilization Review Criteria shall be based on currently established and recognized medical and professional expertise, studies, treatises and literature, and current cumulative information, data and studies on health care services available and provided within the local community.
Care Coordinators. Each Enrollee identified as requiring Care Management Services and those who agree will be assigned a Care Coordinator. Care Coordinators assigned to Enrollees with varying risk levels shall have their overall caseload weighted and a blended overall caseload limit set, taking into account the location of the Enrollee. Contractor will provide the Department with its methodology for assigning Enrollees with varying risk levels for Prior Approval. The Department may review existing caseloads at any time and require a change in methodology or an Enrollee’s assignment to a caseload. Caseloads of Care Coordinators shall not exceed the following standards:
Care Coordinators i. Manage care navigation for demonstration enrollees in patient centered medical homes, emergency department, and during transition from inpatient care
