What is Patient Care and Utilization Management?
GlobalHealth has developed a patient management program to assist in determining what healthcare services are covered and payable under the health plan and the extent of such coverage and payments. The program assists members in receiving the appropriate healthcare and maximizing coverage for those healthcare services. The Medical Director oversees all decisions denying coverage for services for reasons of medical necessity. In the event of a denial, providers and members will be informed by letter of any unmet criteria, standards and guidelines, as well as of the appeal process.
Our patient management staff uses nationally recognized guidelines and resources to guide the pre-service, concurrent, and post-service review processes. Using information obtained from providers, patient management staff applies Milliman & Robertson Health Care Management Guidelines when conducting pre-service and concurrent reviews.
Pre-service Authorization
Certain healthcare services, such as referrals to specialists, hospitalization, and outpatient surgery, require prior authorization with GlobalHealth (or its designee) to ensure coverage for those services. If you do not obtain prior authorization, you may be financially responsible for the services. Your GlobalHealth network Primary Care Physician (PCP) should process referrals for services on your behalf. All Behavioral and Mental Health/Chemical Dependency services are arranged and authorized through Mental Health Network (MHNet).
Concurrent Review
The Concurrent Review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services. All inpatient services extending beyond the initial authorized period will require concurrent review.
Discharge Planning
Discharge Planning may be initiated at the time of the patient’s admission and begins immediately upon identification of post discharge needs during authorization or concurrent review. The discharge plan may include initiation of a variety of services/benefits to be utilized by the member upon discharge from an inpatient stay.
Post-Service Review
The purpose of a Post-Service Review is to retrospectively evaluate the services rendered and analyze potential quality and utilization issues. As well as review all appeals of inpatient concurrent review decisions. The following information will be used for the retrospective review: ER summary, medical record(s) and discharge diagnosis. GlobalHealth’s effort to manage the services provided to members includes the retrospective review of claims submitted for payment, and medical records submitted for potential quality and utilization concerns.