Medical Management

The design of the Medical Management Program is to monitor the appropriateness of all medically necessary and covered services for pre-service care, concurrent review, and post-service care delivered to Aspirus Health Plan members.

The Aspirus Health Plan Medical Management team developed the program in collaboration with Aspirus Health Plan contracted health care providers. The strategy of our Medical Management Program is to promote optimal practice while being sensitive to the current structure of the local delivery systems. All components of the program comply with Federal and State regulations and strive to meet the nationally recognized utilization standards of the National Committee for Quality Assurance (NCQA). The program is designed to make utilization decisions affecting the health care of members in a fair, impartial, and consistent manner. The main goal of the Medical Management Program is to oversee and ensure the quality of relevant care while promoting appropriate utilization of medical services and plan resources.

Medical Management Program Objectives

Provide a structured process to continually monitor and evaluate the delivery of health care and services to our members by:

  • Establishing system-wide health management processes across the continuum of care.
  • Establishing a process for provider feedback regarding utilization.
  • Monitoring indicators to detect possible under- and over-utilization.
  • Periodic auditing of denial decision timeliness.
  • Conducting interviewer reliability audits of all RN Comprehensive Care Coordination Team and the Medical Director.

Improve clinical outcomes through:

  • System-wide collaboration to identify, develop, and implement clinical practice guidelines and programs which address key health care needs of the members.
  • Implementation of clear, consistent Medical Management requirements and key indicators of success.
  • Implementation of Behavioral Health management processes.
  • Development of mechanisms to measure and implement actions to decrease under- and over-utilization.
  • Collaboration with the Quality Improvement Committee/department to assess and implement actions to improve continuity and coordination of care.

Improve practitioner and member satisfaction by:

  • Assessing practitioner and member satisfaction with Medical Management policies and procedures.
  • Promoting appropriate utilization of Aspirus Health Plan resources through efficiency of service.

Meet or exceed established quality standards by:

  • Complying with NCQA standards for the accreditation of Managed Care Organizations.
  • Measuring program performance in accordance with the Health Employer Data Information Set (HEDIS) specifications.

Scope

Primary care/model of care Prior authorization of medical services
Concurrent review decision Post-service review determination
Health Resource Team Disease Management Program
Behavioral Health Care Management Program Chiropractic Care Management Program
Pharmacy Management Program Radiology Benefit Management Program
Health care informatics Emergency services
Technology assessment Affirmative statement on incentives
Reporting Grievance and appeal

Support tools and resources

Policies and Procedures Clinical Practice Guidelines
Literature External Review
Certificate of Coverage Definitions Nationally Published Utilization Management Critera
Conference/Seminar Clinical Experts

The Medical Management department collects data on practitioner satisfaction with the Utilization Management process and reports this information to the Quality Improvement Committee for review and action, as they deem necessary.

Concurrent Review

Concurrent review decisions are reviews for the extension of previously approved ongoing care. This includes the review of inpatient care as it is occurring or ongoing ambulatory care.

Concurrent review provides the opportunity to evaluate the ongoing medical necessity of care and supports the health care provider in coordinating a member’s care across the continuum of health care services.

  • Medical Management staff complete inpatient concurrent review over the phone or via fax.
  • Medical Management staff obtains all data and relevant information including, but not limited to, medical records and communications with practitioners or other consultants.
  • Medical Management staff uses utilization management criteria to review relevant information.
  • Inpatient concurrent review is continuous for the duration of the inpatient stay.
  • Medical Management staff makes urgent concurrent review decisions within 24 hours of receipt of the request. Medical Management staff provides the approval decisions to the practitioners via oral, electronic, or written notification via the facility case managers or discharge planner. Medical Management staff communicates denial decisions verbally or electronically followed by written notification to the practitioner, facility, and member.
  • Concurrent review may include staffing by health care professionals and/or home visits with home health care agencies.
  • Requests to extend a course of treatment previously approved that does not meet the definition of urgent care will be handled as a new request.
  • The Medical Director reviews and renders a determination for all potential medical necessity denials.

Retrospective Review

Post-service decisions are determinations of medical necessity and/or appropriate level of care when the member already received services, for example, retrospective review. Medical Management staff communicates post-service determinations electronically or in writing within 30 calendar days of the request.

The Medical Director reviews and renders a determination for all potential medical necessity or inappropriate level of care denials.

Medical Management Review

Medical Management staff communicates all denials to the practitioner, member, and PCP, if applicable, in writing. All written denial notifications include:

  • The specific reason for the denial.
  • A reference to the benefit provision, guideline, protocol, or other similar criterion on which the denial decision is based.
  • An offer to provide a copy of the actual benefit provision, guideline, protocol, or other similar criterion on which the denial decision was based, upon request.
  • A description of appeal/grievance rights, including the right to submit written comments, documentation, or other information relevant to the appeal/grievance.
  • An explanation of the appeal/grievance process, including the right to member representation and time frames for deciding appeals/grievances.
  • A description of the expedited appeal/grievance process for urgent pre-service or urgent concurrent denial.
  • Notice of the Independent Review Process, if applicable.

Concurrent review decisions are reviews for the extension of previously approved ongoing care for inpatient or ongoing ambulatory care. Concurrent review provides the opportunity to evaluate the ongoing medical necessity of care, and supports the health care provider in coordinating a member’s care across the continuum of health care services.

  • Medical Management staff complete inpatient concurrent review over the phone or via fax.
  • The Medical Management staff obtains all data and relevant information including but not limited to medical records and communications with practitioners or other consultants.
  • Staff uses utilization management criteria to review relevant information.
  • Inpatient concurrent review is continuous for the duration of the inpatient stay.
  • We make urgent concurrent review decisions and verbally notify the practitioner or facility discharge planner/case manager within 24 hours of receipt of the request, followed by written notification for denials.
  • Requests to extend a course of treatment previously approved that does not meet the definition of urgent care will be handled as a new request.
  • The Medical Director or BH Consultant reviews and renders a determination for all potential medical necessity denials.

Post-service decisions are determinations of medical necessity and/or appropriate level of care when the member already received services, for example, retrospective review. Medical Management staff communicate post-service determinations electronically or in writing within 30 calendar of the request. The Medical Director reviews and renders a determination for all potential medical necessity or inappropriate level of care denials.

Chiropractic Care Management Program

The Chiropractic Care Management Program allows chiropractors to work collaboratively with the clinical team to provide services with appropriate authorization. Aspirus chiropractors are encouraged to collaborate directly with primary care and specialty medical services to facilitate the most cost-effective and expeditious pre-service authorizations to participating practitioners within the Aspirus Health Plan network.

The Chiropractic Care Management Program consists of prior authorization determinations of all services from non-participating practitioners. These services will be reviewed for medical necessity and/or coordination of care/services for care the member already received.

  • Staff receives the chiropractic claims via a claim report.
  • Staff obtains the medical records related to the visits for medical review.
  • Staff uses utilization management criteria to review relevant information.

The Clinical team reviews and renders all decisions for coverage for both approvals and medical necessity denials. We do not send letters for approvals of claims payment. We send notification of post-service denial determinations in writing to the chiropractor and member within 30 calendar days of the receipt of the claim.

All written denial determination notification includes:

  • The specific reason for the denial.
  • A reference to benefit provision, guideline, protocol, or other similar criterion on which the denial decision is based.
  • An offer to provide a copy of the actual benefit provision, guideline, protocol, or other similar criterion on which the denial decision was based, upon request.
  • A description of appeal/grievance rights, including the right to submit written comments, documentation, or other information relevant to the appeal/grievance.
  • An explanation of the appeal/grievance process including the right to member representation and time frames for deciding appeals/grievances.
  • A description of the expedited appeal/grievance process for urgent prior authorization or concurrent denial.
  • Notice of the Independent External Review Process, if applicable.

Complex Care Management Program

With the help of the RN Comprehensive Care Coordination Team

Are you struggling with a chronic condition or a series of complex health issues? Not to worry–our RN Comprehensive Care Coordination Team is available to help advocate for and support you! The RN Comprehensive Care Coordination Team is available to:

  • Assist in coordinating care with your specialty doctors.
  • Assist in coordinating care in the hospital, at the clinic, and at home.
  • Facilitate access to services and programs available within Aspirus and the community.
  • Work with you and your doctors to develop a personalized plan of care to help you improve your quality of life.
  • Help you understand health issues and treatment options so you can make smart health care choices.
  • Partner with you and your doctors to help identify goals and support your progress.

Care Coordination

Aspirus Health Plan’s key objective is to improve overall health and wellness for our patients, like you. That’s why we offer a RN Comprehensive Care Coordination program at no additional cost to you! This program offers you increased access to services and resources to assist in managing and improving your health and wellness. The diseases below are covered with the program:

  • Diabetes
  • Congestive heart failure
  • High blood pressure

Once enrolled, the RN Comprehensive Care Coordinator will work with you and your doctors to develop a personalized plan of care that includes goal setting, medication adherence, lifestyle change, and tools for self-management. Your personalized plan will help you integrate healthy lifestyle changes and chronic condition self-management into your daily life.

Behavioral Health Care Management Program

The Behavioral Health Care (BH) Management provides a mechanism to optimize use of the member’s health care benefits while providing high-quality integrated health care to members with mental and/or substance abuse disorders. Services include, but are not limited to:

  • Inpatient and concurrent certification
  • Pre-service request review
  • Post-service review

The Behavioral Health Care Management does not require triage or the prior authorization process for a member to contact, or make an appointment with, a behavioral health care practitioner. It is the practitioner’s responsibility to provide a treatment plan for Aspirus Health Plan services. The program requires prior authorization determination of all services referred to inpatient facilities, and non-participating practitioners or providers. We review these services for medical necessity, potential redirection to an appropriate Aspirus practitioner, and/or coordination of care/services.

  • Providers submit requests via facsimile, telephone, or mail.
  • The Medical Management staff obtains all data and relevant information including, but not limited to, medical records and communications with practitioners or other consultants.
  • Medical Management staff uses utilization management criteria to review relevant information.
  • Medical Management staff reviews inpatient facility care prior to, or within, 24 business hours of admission, then concurrently according to accepted criteria and guidelines.
  • Medical Management staff communicates non-urgent pre-service approval decisions to the practitioners and members, via oral, written, or electronic notification, within 15 calendar days of the request. Medical Management staff communicates non-urgent pre-service denials within 15 calendar days of the request via written or electronic notification.
  • Medical Management staff provides urgent pre-service approval decisions to the practitioners and members via oral, written, or electronic notification within 72 hours of the request. MM staff communicates urgent denials verbally within 72 hours of the request, followed by written or electronic notification.
  • Medical Management staff sends approval decision letters for select services to the member, the PCP (if applicable), the servicing practitioner, and the facility, if appropriate.
  • The Chief Medical Officer or the Associate Director of Behavioral Health reviews and renders a determination for all potential medical necessity denials.