Medicare - Medical Management Programs |
Program Description
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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 beneficiaries, while promoting the efficient delivery of health care.
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Health Care Management Decisions
Health care treatments, drugs and supplies that are not part of the member’s benefit plan or are not reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve function 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, and post-service review.
All providers must cooperate with the decisions, rules and regulations established by ConnectiCare's Quality Improvement and Utilization Management Programs. ConnectiCare works with an independent quality improvement organization to develop quality improvement and utilization management programs to ensure compliance with federal standards.
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 select elective surgical procedures
• Pre-authorization for elective care from out-of-plan providers
• 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
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
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 in a timeframe that is compliant with Centers for Medicare & Medicaid Services (CMS) regulations. ConnectiCare will notify the member and the attending physician of the decision in writing. For questions about pre-authorization of procedures, call 1-800-508-6157.
When an adverse determination has been issued, providers have the right to the following:
• Provider Appeals Process
Note: Case managers are also available for other Utilization Management questions from 8 a.m. to 5 p.m., Monday through Friday at 1-800-508-6157. After hours, please leave a voicemail message.
