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Medical management

The goal of our medical management team is to help members reach their best levels of health. A care manager is assigned to each member. They’re a part of the medical management team. And their job is to make sure members get all the care and services they need.

Care management

Care management

Our care management department provides support to members based on each individual’s risks and needs. These care needs are assessed by licensed nurses, social workers and counselors, as well as nonclinical professionals. We use a biopsychosocial (BPS) model to help us identify what care our members need. Then, the integrated case manager performs a health risk assessment to determine the member’s medical, behavioral health and BPS status.

 

Care managers work with members, their families, primary care physicians (PCPs), psychiatrists, substance abuse counselors or any other health care team members to achieve an efficient and cost-effective care plan. Care management teaches members about their specific diseases and how to prevent symptoms from getting worse. Our goal is to maintain or improve our members’ health.

 

Our care management programs include:

 

  • Pregnancy outreach and high-risk obstetrics

  • Special health care needs

  • Behavioral health and substance abuse

Disease management

Disease management

Our disease management program helps members manage specific conditions. We assist with:

 

  • Regular communications

  • Targeted outreach and support

  • Focused education

 

The conditions in our program include:

 

  • Diabetes

  • Asthma

  • Heart failure

  • Sickle cell anemia

  • Hepatitis C

  • Obesity

  • HIV and AIDS

Quality management

Quality management

We are dedicated to providing high-quality care for our members. To do this, we monitor and evaluate our performance on a regular basis. This is the responsibility of our Quality Management (QM) department. QM is always making sure we’re doing the right thing for the right reasons.

Utilization management

We follow Maryland HealthChoice’s rules when we make our health care decisions. There are no rewards or financial incentives for our providers or staff for denying or reducing members’ benefits. You can submit your prior authorization claims with Eviti® Connect or evicore healthcare®.

 

 

Eviti Connect

 

 

We use Eviti Connect, a NantHealth® online platform, for utilization management services and oncological care. Our providers use Eviti Connect to validate cancer treatment and supportive medications that require prior authorization. Treatment plans are available on the Eviti Payer dashboard. You can find training and support on the Eviti Connect website.

 

You can learn more about Eviti Connect by:

 

 

 

eviCore healthcare

 

 

We use eviCore healthcare for utilization management services for the following programs:

 

  • Musculoskeletal (pain management)

  • Radiology management (includes advanced imaging such as CT, MRI, MRA, PET scans)

  • Cardiology (cardiac imaging)

 

You can contact eviCore by:

 

 

Call us

If you have any questions, you can call Provider Relations at 1-866-827-2710 (TTY: 711). And ask to speak to our care management department.