Care Management. The Contractor’s protocol for referring members to care management shall be reviewed by OMPP and shall be based on identification through the health needs screening or when the claims history suggests need for intervention. In addition to population-based disease management educational materials and reminders, these members should receive more intensive services. Members with newly diagnosed conditions, increasing health services or emergency services utilization, evidence of pharmacy non-compliance for chronic conditions and identification of special health care needs should be strongly considered for case management. Care management services include direct consumer contacts in order to assist members with scheduling, location of specialists and specialty services, transportation needs, 24-Hour Nurse Line, general preventive (e.g. mammography) and disease specific reminders (e.g. Xxx X0X), pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency services. The Contractor shall make every effort to contact members in care management telephonically. Materials should also be delivered through postal and electronic direct-to-consumer contacts, as well as web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth grade reading level. All members with the conditions of interest shall receive materials no less than quarterly. The Contractor shall document the number of persons with conditions of interest, outbound telephone calls, telephone contacts, category of intervention, intervention delivered, mailings and website hits. Care management shall be coordinated with the Right Choices Program for members qualifying for the Right Choices Program. However, the Right Choices Program is not a replacement for care management.
Care Management. A set of Member-centered, goal-oriented, culturally relevant, and logical steps to assure that a Member receives needed services in a supportive, effective, efficient, timely, and cost-effective manner. Care Management is also referred to as Care Coordination.
Care Management. Functions of the MCO should support and enhance member-centered care. Designing member- centered plans that effectively and efficiently identify the personal experience outcomes and meet the needs and support the long term care outcomes of members and monitor the health, safety, and well-being of members are the primary functions of care management. Member- centered planning supports: 1) the success of each individual member in maintaining health, independence and quality of life; 2) the success of the MCO in meeting the long-term care needs and supporting member outcomes while maintaining the financial health of the organization; and
Care Management the provision of person-centered, coordinated activities to support Enrollees’ goals as described in Section 2.5.E of this Contract.
Care Management. The Contractor shall provide Care Management activities to appropriate Enrollees as described in this Section and further specified by EOHHS.
Care Management. Care Management services work to help ensure that you receive appropriate and cost-effective medical care. Your role in the Care Management process is simple, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you to call Customer Service to verify that you meet the required criteria for claims payment and to help us identify admissions that might benefit from case management. PRIOR AUTHORIZATION Your coverage for some services depends on whether the service is approved before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary and eligible for coverage under this plan. We will let you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required: • Before you receive certain medical services and drugs, or prescription drugs • Before you schedule a planned admission to certain inpatient facilities • When you want to receive the higher benefit level for services you receive from an out-of-network provider
Care Management. The Health Plan shall be responsible for the management and continuity of medical care for all enrollees. The Health Plan shall maintain written case management and continuity of care protocols that include the following minimum functions:
Care Management. Care Management services work to help ensure that you receive appropriate and cost-effective medical care. Your role in the Care Management process is simple, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you to call Customer Service to verify that you meet the required criteria for claims payment and to help us identify admissions that might benefit from case management. PRIOR AUTHORIZATION Your coverage for some services depends on whether the service is approved before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary and eligible for coverage under this plan. We will let you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required: Before you receive certain medical services and drugs, or prescription drugs Before you schedule a planned admission to certain inpatient facilities When you want to receive benefits for services from an out-of-network provider How to Ask for Prior Authorization The plan has a specific list of services that must have prior authorization with any provider. The list is on our website at xxxxxxxxxx.xxx. Before you receive services, we suggest that you review the list of services requiring prior authorization. LifeWise Connect providers will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services. Generally this plan does not cover services from providers not in the LifeWise Connect network. If there is not a LifeWise Connect provider that can provide the service needed, see Services from Out-of-Network Providers for more information. We will respond to a request for prior authorization within 5 calendar days of receipt of all information necessary to make a decision. If your situation is clinically urgent (meaning that your life or health would be put in serious jeopardy if you did not receive treatment right away), you may request an expedited review. Expedited reviews are responded to as soon as possible, but no later than 48 hours after we get the all information necessary to make a decision. We will provide our dec...
Care Management. HMHP may contract with Payors for HMHP to administer care management, utilization management and quality assurance programs for Payors. The Parties acknowledge and agree that such Payor programs will solely cover such Payors’ respective Enrollees and that HMHP will use clinical data relating solely to those Enrollees for this purpose.
Care Management. A set of individualized, person-centered, goal-oriented, culturally relevant services to assure that an Enrollee receives needed services in a supportive, effective, efficient, timely and cost-effective manner. Care Management emphasizes prevention, continuity, and coordination, that support linkages across the full continuum of Medicare and Medicaid Covered Services based on individual Enrollee strength-based needs and preferences.
