Care Management Services
A Comprehensive Service Designed to Meet Your Health Care Needs
A population-based approach that identifies individuals with chronic diseases in order to prevent the complications, consequences, and progression of disease. This is accomplished through education, patient support and contact, and is intended to facilitate physician communication.
Contains cost by preventing the need for services.
Using a preventive and wellness approach to healthcare.
Early identification and intervention of cases that could potentially lead to high claims utilization, and severe economic impact to the employer.
Health Management reinforces wellness and disease prevention.
For more detailed information, please visit our Health Management Page.
Patients who have been identified with a potentially large claim diagnosis or complicated medical condition, are assigned to a Case Management Nurse who monitors their treatment and progress.
Examples of potentially large claim diagnoses include, but are not limited to:
Transplants
Cancer
Spinal cord injuries, & neurological diseases
Premature births and high-risk pregnancies
Traumatic injuries
Advantages for the patient:
Case Manager utilization review
Patient resource and support
Consistent contact point for providers
Continuity of care
Pre-certification is the process of reviewing prospective procedures and inpatient hospitalizations for medical necessity.
Review for medical necessity is generally done for the following:
Outpatient Surgery
Inpatient Hospitalizations
Therapy OT, PT, ST
Home Health Care (HHC)
Durable Medical Equipment (DME)
MRI, CT, PET Scans
Pre-certification also verifies the most appropriate setting or facility for care. Pre-certification can:
Promote prompt intervention of potentially large claims.
Reduce deductibles for covered participants.
Reduce the length of stay.
Control group health care costs.
Identify alternate treatment plans.
Utilization Review is a program designed to ensure that all Covered Persons receive necessary and appropriate health care while avoiding unnecessary expenses.
Admission Review
CG Care is notified of a patients admission to the hospital through the ER or doctors office. Notification is to be completed within 24-48 hours of the admission to initiate the certification process.
Concurrent/Continued Stay Review
Inpatient stay review done when the patient has remained in after the initial number of days authorized through pre-certification.
Discharge Planning Review
Pre-certification that takes place while the client is still inpatient to make sure that all of the services they will require after discharge are in place.
Retrospective Review
Pre-certifications that take place after the service has been rendered. These reviews can be costly and time consuming, as they require extensive chart review. Subsequently, these reviews are limited to emergency services only. For example if a person experiences a heart attack, treatment must be provided.
(Please check with your plan for availability).