Common use of Individual Case Management Clause in Contracts

Individual Case Management. Case Management is the process by which the Plan, in its sole discretion, identifies alternative treatment modalities commensurate with the Member’s diagnosis profile and consults with the patient and attending Professional Provider(s). Notwithstanding the foregoing, all decisions regarding the treatment to be provided to a Member shall remain the responsibility of the treating Professional Provider(s) and the Member working with the Plan. The Plan shall provide such alternative benefits, in its sole discretion, only when, and for so long as, it determines that the procedures/Services are Medically Necessary and Appropriate, cost effective, and that the total benefits paid for such procedures/Services do not exceed the total benefits to which the Member would otherwise be entitled under this Agreement in the absence of alternative benefits. The Plan will provide Individual Case Management Services for those Members identified by the Plan as falling into one (1) or more of the following diagnosis profiles of illnesses or injuries, or such other diagnosis profiles as deemed appropriate from time to time by the Plan: Illnesses Acquired Immune Deficiency Syndrome Cystic Fibrosis Amyotrophic Lateral Sclerosis Diabetes Mellitus Autism Spectrum Disorders Multiple Sclerosis Carcinoma Muscular Dystrophy Cardiac Surgery Neonatal High Risk Infants Cerebral Palsy Osteomyelitis Cerebrovascular Accident Psychiatric Diagnoses Chronic Obstructive Pulmonary Disease Sickle Cell Anemia Complications of Chronic Disease Processes Xxxxx Bifida Injuries Amputations Paralytic Syndromes Major Head Trauma Severe Xxxxx Multiple Fractures Spinal Cord Injury The Plan in its sole discretion, reserves the right to limit access and/or modify benefit(s) for any individual Member, regardless of disease or condition, when the Plan identifies utilization patterns that could potentially result in harm to such Member or the public.

Individual Case Management. Case Management is the process by which the Plan, in its sole discretion, identifies alternative treatment modalities commensurate with the Member’s diagnosis profile and consults with the patient and attending Professional Provider(s). Notwithstanding the foregoing, all decisions regarding the treatment to be provided to a Member shall remain the responsibility of the treating Professional Provider(s) and the Member working with the Plan. The Plan shall provide such alternative benefits, in its sole discretion, only when, and for so long as, it determines that the procedures/Services are Medically Necessary and Appropriate, cost effective, and that the total benefits paid for such procedures/Services do not exceed the total benefits to which the Member would otherwise be entitled under this Agreement in the absence of alternative benefits. The Plan will provide Individual Case Management Services for those Members identified by the Plan as falling into one (1) or more of the following diagnosis profiles of illnesses or injuries, or such other diagnosis profiles as deemed appropriate from time to time by the Plan: Illnesses Acquired Immune Deficiency Syndrome Cystic Fibrosis Amyotrophic Lateral Sclerosis Diabetes Mellitus Autism Spectrum Disorders Multiple Sclerosis Carcinoma Muscular Dystrophy Cardiac Surgery Neonatal High Risk Infants Cerebral Palsy Osteomyelitis Cerebrovascular Accident Psychiatric Diagnoses Chronic Obstructive Pulmonary Disease Sickle Cell Anemia Complications of Chronic Disease Processes Xxxxx Bifida Injuries Amputations Paralytic Syndromes Major Head Trauma Severe Xxxxx Multiple Fractures Spinal Cord Injury The Plan Plan, in its sole discretion, reserves the right to limit access and/or modify benefit(s) for any individual Member, regardless of disease or condition, when the Plan identifies utilization patterns that could potentially result in harm to such Member or the public.