Patient care management

We help members get answers to questions about their disease and offer support to help manage chronic health needs.

Our program supports patient self-management through:

• Telephone counseling
• Care reminders
• Referrals
• Long-term patient advocacy and support.

A member can be identified for case management based on:

• Diagnosis
• Acute injury
• Health care provider referral
• Member's own request 

Case Management is free of charge. It provides a registered nurse as a resource during a time where health care may be intense or confusing.

Your patient's case manager works with our network providers to meet your patient's needs with quality cost-effective care.

The utilization management team reviews the appropriateness of medical services that members (your patients) receive before and after services are provided. As part of the review, the team uses:

• Behavioral health outpatient care
• Concurrent reviews
• Discharge planning
• Home health care services
• Hospice care
• Inpatient hospital admissions
• Pre-admission certification
• Prior authorization
• Skilled nursing facility & rehabilitation care

These tools allow us to ensure members receive services and supplies that are medically appropriate and necessary for their condition. 

Utilization management also identifies and evaluates a patient's health care needs after hospital discharge and directs members to specific outpatient providers when needed.