Medical Case Management Program

Our philosophy is “members first” and we strive to make it evident in all that we do. Whether we are determining medical necessity for services or collaborating with patients, families, and providers for a smooth transition of care, we know that when members are receiving the care and compassion they deserve, they are not only more likely to participate in the journey toward their goal for optimal health, they are more likely to reach it.

The Utilization Management (UM) team is comprised of the Director of UM, review nurses, customer service representatives, and physician reviewers for all grievances and appeals. The team provides the following services:

  • Pre-certification review for elective procedures/hospitalizations/services

  • Outpatient services review for outpatient procedures/services

  • Continued stay review for inpatient care upon admission for hospital admissions (medical, mental health, and substance abuse)

  • Review of medical necessity and guidelines for DME, HHC, PT/OT/ST, CT, MRI, PET scan requests

  • Clinical guideline review for injections, infusion therapy, radiation therapy,

  • Screening for the need for medical case management services


Clinical factors that trigger case management referral include but are not limited to the following:

  • Hospital admission with a longer than expected length of stay, or a length of stay that is seven days or more.

  • Subsequent admissions by the same member within a 30-day period

  • Three or more hospital admissions by an individual member within one calendar year

  • High risk pregnancies

  • Catastrophic illness, accidents resulting in trauma, severe injuries

  • Kidney/liver/heart failure

  • Potential transplant candidate

  • New or recurrent malignancies

  • Major cardiac surgeries, amputations

  • Unstable chronic conditions (medical, mental health, substance abuse)

  • Any service/drug requirements over $20,000

In addition to these listed triggers, claim reporting is used to identify potential case management interventions for high dollar care either inpatient or outpatient, frequent emergency room utilization, and high patient risk score based on a combination of primary diagnosis, comorbidities, gaps in care, and pharmacy spend.