Commercial - Medical Management Programs |
Program Description
|
The goal of the Medical Operations Department is to ensure that
members have access to cost-effective, quality health care. Health care is
provided by participating practitioners and other health care providers and
coordinated through ConnectiCare and/or its designated vendors. We utilize a
case management model which promotes and enhances the level of health care for
ConnectiCare members, while promoting the efficient delivery of health care.
|
Health Care Management Decisions
Health care treatments, drugs and supplies that are not part of the member’s
benefit plan or are not medically necessary are not covered. We determine if a
treatment, drug or supply is medically necessary and, therefore, covered.
Additionally, if health services can be provided in more than one medically
appropriate setting, ConnectiCare may determine which setting is eligible for
benefit coverage and the health services must be provided in that setting in
order for the member to be eligible for benefit coverage. These benefit
determinations are made through various health care management procedures, including pre-service review,
concurrent review, inpatient hospital readmission review, post-service review, and a reconsideration process.
Note: ConnectiCare reserves the right to use third-party vendors
to administer benefits, including utilization management services.
Pre-service Review (before services are rendered)
• Pre-admission certification for elective hospitalization
• Pre-authorization for medical necessity of selected elective surgical
procedures
• Pre-authorization for elective care from out-of-plan providers (excluding
Point-of-Service plans)
• Pre-authorization for non-acute facility admissions (sub-acute, skilled
nursing facility, hospice, etc.), home health care, Durable Medical Equipment
(DME)
Note: Admission to a SNF for rehabilitation, in the absence of a
preceding hospitalization or acute episode of illness or injury, requires
pre-authorization and is subject to medical necessity review.
Concurrent Review (while services are being rendered)
• Evaluation of discharge readiness based on severity of illness and intensity
of services received during an inpatient admission
• Assessment of appropriateness of site for care; including the medical necessity of emergency/urgent admissions
• Facilitation of care delivery throughout the continuum of care
Inpatient Hospital Readmission Review
(Effective March 1, 2012)
• Review resulting from a member who is discharged from a hospital and is then readmitted to the same hospital or same hospital network within 7 days of the hospital discharge
• Evaluation of clinical information related to both the initial hospital admission and readmission to determine if the readmission is related or "connected" to the original inpatient stay
Post-service Review (after services are rendered)
• Review of clinical information for medical necessity and appropriateness of
service
Reconsideration Process (upon an adverse medical determination)
• Review by the clinical peer reviewer who made the initial adverse
determination, only upon request by the physician who originally requested
approval of the services
Decision-Making
When health care management decisions are made, they are based on the
member’s benefit plan and the appropriateness of the proposed health care
treatments, drugs and supplies for that member. We do not reward practitioners
or other individuals conducting utilization review for issuing denials of
coverage for health care treatments, drugs, and supplies. We offer no incentives
to promote decision making that would result in inappropriate denials of
services.
We will make pre-authorization and pre-service determinations within two (2)
business days of receipt of all necessary clinical information, but no later
than fifteen (15) days from receipt of the request. ConnectiCare will notify the
member and the attending physician of the decision in writing. For questions
about pre-authorization of procedures, call (860) 674-5860 or
1-800-562-6833.
When an adverse determination has been issued, providers have the right to
the following:
• Reconsideration Process
• Provider Appeals Process
Note: Case managers are also available for other Utilization
Management questions from 8 a.m. to 5 p.m., Monday – Friday at 860-674-5860 or 1-800-562-6833. After hours, please leave a voicemail message.
