8 Health Care Management Services
8.5 Case Management
Multiple clinical and coverage determination guidelines are used to review the appropriateness of a service that has been rendered or requested to determine the care is reasonable and necessary for the diagnosis or treatment of illness or injury, provided in the most appropriate level of care, and is not furnished for the convenience of the member or provider. The clinical guidelines used may include any of the following based on the type of request: CMS, National and Local Coverage and Benefit Guidelines, current editions, MCG Guidelines (formerly Milliman Care Guidelines®), IntegraNet Medical Policies and Clinical Utilization Management Guidelines to review the medical necessity and appropriateness of physical health services, unless superseded by state requirements or regulatory guidance.
These criteria and guidelines are objective and provide a rules-based system for screening proposed medical health care based on patient-specific, best medical care processes and consistently match medical services to patient needs, based upon clinical appropriateness.
The criteria’s comprehensive range of level-of-care alternatives is sensitive to the differing needs of adults, adolescents, and children. When using the criteria to match a level of care to the member’s current condition, all reviewers consider the severity of illness and comorbidities, as well as episode-specific variables. Their goal is to view members in a holistic manner to ensure they receive necessary support services within a safe environment optimal for recovery.
Criteria and guidelines are reviewed and approved annually by members of the Clinical Care Policy Board and updated when appropriate. Input from the medical community is solicited and used in developing and updating policies. Policies and procedures for application of medical necessity criteria are reviewed and approved annually.
Getting the best care in the most appropriate setting is key to achieving the best outcomes for our IntegraNet members. These members rely on their health care professionals and their health plan to help coordinate this important aspect of their care. To do this, timely communication is essential.
Ensuring that you provide the correct and complete clinical information at the correct time when requesting a medical necessity review when clinical information is needed.
If the information provided does not support medical necessity, the service cannot be approved under Medicare law. Please provide the necessary information to justify the services you are requesting at the time of the request to allow for an appropriate decision to be made. Any service determined to require a clinical review will be processed in accordance with:
UM criteria are made available to practitioners upon request. If a medical necessity decision results in an adverse determination, practitioners are welcome to discuss the denial decision with a Medical Director.
For additional information, to speak to a Medical Director, obtain UM criteria or for any inquiries, contact may be made by calling 281-591-5289.