Medical Case Management Program
This Benefit Is For Individuals Without Medicare
Certain medical conditions may result in complicated
or interrelated treatment. In order to address
these cases, the medical review agency
administers both a voluntary and a mandatory
medical case management program.
The medical case management program uses
physicians, nurses and other health care
professionals to help coordinate the most appropriate
and cost-effective treatment for such
conditions. Treatment plans are continually
monitored to ensure that services are medically
appropriate, properly coordinated, and cost
effective. This helps you get the most benefit
from the plan without compromising the quality
or integrity of care. During the course of
this process, you may be required to obtain an
independent medical examination (IME) to
help determine medical necessity.
For most cases, participation in the case
management program is voluntary. However,
in certain circumstances, participation in case
management may be required. The Board of
Trustees has directed the plan's medical consultant
and the plan's medical review agency
to examine medical records and determine
if a patient's use of medical services and
medications is unsafe, potentially harmful,
excessive, or medically inappropriate. Based
on this review and determination, the plan
may require the patient to participate in and
comply with the medical case management
program as a condition of continued payment
for services under the plan. Mandatory case
management may include, but not be limited
to, designating a primary physician (MD
or DO) to coordinate care, and designating
a single hospital and pharmacy to provide
covered services and medications. The plan
has the right to deny payment for any services
received outside of the required case management
program. The patient has the right to
appeal the plan's determination and the
mandatory case management plan through the
appeals procedures described in this booklet
(please see "Claims and Appeals Rules" on
pages 145-150).
In all situations, the plan reserves the right to
reduce or deny benefits if certain ongoing care
is determined medically unnecessary or inappropriate
for a patient's condition.
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