Case Management Programs Clause Samples
The Case Management Programs clause establishes procedures for managing and resolving disputes or claims that arise during the course of a contract. Typically, this clause requires the parties to participate in structured processes such as mediation, arbitration, or other alternative dispute resolution methods before resorting to litigation. For example, it may mandate that both parties attend a case management conference or submit to a neutral third-party review. The core function of this clause is to streamline dispute resolution, reduce litigation costs, and encourage efficient, amicable settlements.
Case Management Programs. In accordance with 5101:3-26-03.1(A)(8), MCPs must offer and provide comprehensive case management services which coordinate and monitor the care of members with specific diagnoses, or who require high-cost and/or extensive services. The MCP’s comprehensive case management program must also include a Children with Special Health Care Needs component as specified below.
i. Each MCP must inform all members and contracting providers of the MCP’s case management services.
ii. Children with Special Health Care Needs (CSHCN): CSHCN are a particularly vulnerable population which often have chronic and complex medical health care conditions. In order to ensure compliance with the provisions of 42 CFR 438.208, each MCP must establish a CSHCN component as part of the MCP’s comprehensive case management program. The MCP must establish a process for the timely identification, completion of a comprehensive needs assessment, and providing appropriate and targeted case management services for any CSHCN. CSHCN are defined as children age 17 and under who are pregnant, and members under 21 years of age with one or more of the following: -Asthma -HIV/AIDS -A chronic physical, emotional or mental condition for which they are receiving treatment or counseling -Supplemental security income (SSI) for a health-related condition -A current letter of approval from the Bureau of Children with Medical Handicaps (BCMH), Ohio Department of Health
iii. The MCP’s comprehensive case management program must include, at a minimum, the following components:
a. Identification - The MCP must have a variety of mechanisms in place to identify members potentially eligible for case management. These mechanisms must include an administrative data review (e.g., diagnosis, cost threshold, and/or service utilization) and may include provider/self referrals, telephone interviews, information as reported by MCEC during membership selection, or home visits.
Case Management Programs. In accordance with 5101:3-26-03.1(A)(8), MCPs must offer and provide comprehensive case management services which coordinate and monitor the care of members with specific diagnoses, or who require high-cost and/or extensive services. The MCP’s comprehensive case management program must also include a Children with Special Health Care Needs component as specified below.
i. Each MCP must inform all members and contracting providers of the MCP’s case management services.
ii. Children with Special Health Care Needs (CSHCN): CSHCN are a particularly vulnerable population which often have chronic and complex medical health care conditions. In order to ensure compliance with the provisions of 42 CFR 438.208, each MCP must establish a CSHCN component as part of the MCP’s comprehensive case management program. The MCP must establish a process for the timely identification, completion of a comprehensive needs assessment, and providing appropriate and targeted case management services for any CSHCN. CSHCN are defined as children age 17 and under who are pregnant, and members under 21 years of age with one or more of the following: - Asthma - HIV/AIDS - A chronic physical, emotional or mental condition for which they are receiving treatment or counseling - Supplemental security income (SSI) for a health-related condition - A current letter of approval from the Bureau of Children with Medical Handicaps (BCMH), Ohio Department of Health
Case Management Programs. The Aetna Case Management program is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs in accordance with the Plan through communication and available resources to promote quality, cost-effective outcomes. Those Plan Participants with diagnoses and clinical situations for which a specialized nurse, working with the Plan Participant and their physician, can make a material impact to the course or outcome of care and/or reduce medical costs will be accepted into the program at Aetna’s discretion. Case management staff strives to enhance the Plan Participant’s quality of life, support continuity of care, facilitate provision of services in the appropriate setting and manage cost and resource allocation to promote quality, cost-effective outcomes in accordance with the Plan. Case Managers collaborate with the Plan Participant, family, caregiver, physician and healthcare provider community to coordinate care, with a focus on closing gaps in the Plan Participant’s care. Aetna targets two types of case management opportunities: • Complex Case Management targets Plan Participants who have already experienced a health event and are likely to have care and benefit coordination needs after the event. The objective for Case Managers is to identify care or benefit coordination needs which lead to faster or more favorable clinical outcomes and/or reduced medical costs. • Proactive Case Management targets Plan Participants, from ▇▇▇▇▇’s perspective, who are misusing, over-using or under-utilizing the health care system, leading them towards avoidable and costly health events. This program’s objective is to confirm gaps in Plan Participants’ care leading to their over-use, misuse, or under-use, and to work with the Plan Participant and their physician to close those gaps. Case management programs can vary based on the level of advocacy and overall intensity of the programs. The variation is determined by the changing the thresholds by which Plan Participants are identified for outreach. The various case management program options include: • Aetna Flexible Medical ModelSM - This program provides the Customer with the option to purchase more clinical resources devoted specifically to their Plan Participants. The Flex Model provides a Single Point of Contact Nurse (SPOC Nurse) and designated team to handle all case management activities for three levels of Flex Model Options, as elected. T...
Case Management Programs. In accordance with 5101:3-26-03.1(A)(8), MCPs must offer and provide comprehensive case management services which coordinate and monitor the care of members with specific diagnoses, or who require high-cost and/or extensive services. The MCP’s comprehensive case management program must also include a Children with Special Health Care Needs component as specified below.
i. Each MCP must inform all members and contracting providers of the MCP’s case management services.
ii. Children with Special Health Care Needs (CSHCN): CSHCN are a particularly vulnerable population which often have chronic and complex medical health care conditions. In order to ensure compliance with the provisions of 42 CFR 438.208, each MCP must establish a CSHCN component as part of the MCP’s comprehensive case management program. The MCP must establish a process for the timely identification, completion of a comprehensive needs assessment, and providing appropriate and targeted case management services for any CSHCN. CSHCN are defined as children age 17 and under who are pregnant, and members under 21 years of age with one or more of the following: -Asthma -HIV/AIDS -A chronic physical, emotional or mental condition for which they are receiving treatment or counseling -Supplemental security income (SSI) for a health-related condition -A current letter of approval from the Bureau of Children with Medical Handicaps (BCMH), Ohio Department of Health Appendix G Covered Families and Children (CFC) population Page 10
iii. Comprehensive Case Management Program
1. The MCP must have a process to inform members and their PCPs in writing that they have been identified as meeting the criteria for case management, including their enrollment into case management services.
2. The MCP must assure and coordinate the placement of the member into case management — including identification of the member’s need for case management services, completion of the comprehensive health needs assessment, and timely development of a care treatment plan. This process must occur within the following timeframes for:
a) newly enrolled members, 90 days from the effective date of enrollment; and
b) existing members, 90 days from identifying their need for case management.
3. The MCP’s comprehensive case management program must include, at a minimum, the following components: