Medical Management Program

The medical management program ensures the provision of appropriate health care to its members while addressing the effectiveness and quality of the care. The delivery of health care services is monitored and evaluated to identify opportunities for improvement. The program provides for a systematic process to promote the access of medically appropriate care in a timely, efficient manner across the network through care/complex case navigation, pre-authorization/referrals, admission/concurrent reviews, chronic disease navigation programs and population health management.

 

The primary goal of the medical management program is to measurably improve the utilization of care and services to our members in a way that is financially responsible and responsive to their individual health care needs. This goal is achieved by meeting the following objectives:

  • Promote and provide an appropriate allocation of health care services to our members
  • Perform utilization processes with minimal disruption to the delivery of care and services, including clinical information gathering, documentation review, and communication of utilization management decisions
  • Identify members for social service referrals, care, complex case or chronic disease navigation programs
  • Assess medical management program performance by soliciting input from members and practitioners through surveys annually
  • Develop interventions based on input received from members and practitioners to improve the quality of services to all customers
  • Educate practitioners on the scope of the medical management program and Clinical Services division

To view, a list of medical pre-authorization and notification requirements visit The Health Plan’s provider secure website at myplan.healthplan.org.