Utilization Management and Case Management Programs

Dear Participant:

We are excited to be working with you and supporting you in meeting your health care goals. Our multifaceted programs are designed to work collaboratively with you and your healthcare providers to empower you to make informed decisions about your health and health care. We keep our focus on you and your evolving needs as we assist you in your healthcare journey.

Through our utilization management program, our nurses and customer support staff:

  • Work with you and your providers to make sure you receive quality care that is most appropriate for your health condition.
  • Work with you and your providers to make sure services are delivered at the most appropriate, safe level of care meaning that you are not admitted to the hospital when the services could be delivered in your physician’s office or in your home by a home health agency.
  • Assist you with finding network providers in your area who can deliver safe, quality of care. Using network providers maximizes your health plan benefits and limits your out-of-pocket expenses.
  • Assist you with managing and maximizing your health plan benefits.
Our Case Management program provides support and/or information that you may need to meet your health care goals. Our Case Management team also provides the education and support you may need to follow the treatment plan ordered by your physician – such as medications, special diets, exercise programs, or follow-up appointments. Once enrolled in the program, you have access to a wide variety of web-based health education information that you can read at your convenience then discuss with your assigned primary case manager. This case manager is a registered nurse and will be your point of contact when you need additional assistance in meeting your health care goals as long as you remain eligible to receive benefits under the health plan. This program is voluntary and available to everyone. You may self-refer to this program by calling us at 888-801-1910 and selecting option 2.

The Pre-Admission and Discharge Planning Support Program provides educational and coordination services to participants who are having an elective procedure. Educational materials and/or sessions with your assigned case manager explain the procedure to ensure you have the understanding that you need to make an informed decision about this treatment and understand what to expect before, during, and after the procedure. The information provided helps you understand how to best prepare for the procedure to reduce or eliminate the potential for complications and support positive outcomes. It’s important that you or your physician notify us as early as possible once you have decided to have an elective procedure so there is time to provide the information you need to make informed decisions and plan for a speedy recovery.