Providing Care to Manage Complex Health Conditions
Our Care Management Team offers a robust approach to evaluating the effectiveness of care members receive. Through identifying risk, needs, and goals, we develop action plans and provide exceptional levels of care to our most vulnerable members. This involves coordinating a variety of services to make sure that members’ needs are met.
We monitor the care management process with care-usage reviews as well as analysis that identifies potential for care coordination, disease management, and members who may be at risk for improper use of care resources. Our providers can access care management resources for patients in several ways, through prior authorization requests, our customer service department or through a case management referral.
Care Management Programs
We offer a variety of programs that follow specific guidelines to ensure our health care services are efficient and effective. Our Care Management Team uses clinical and evidence-based guidelines as tools in the care management process.
The Care Management Team consists of clinical and nonclinical staff in the following areas:
- Case Management
- SSI and SNAP Referrals
- Utilization Management / Prior Authorization
- Health Coaching Program
- Health Homes
- Utilization Management
- Patient Review and Coordination (PRC) program.
Continuity and Transitions of Care
From time to time, member benefits may be transferred from one plan or primary care provider to another or expire during a course of treatment through termination of the contract, dis-enrollment, or exhaustion of available benefits. At times like these, we promote smooth and seamless continuity and transition of medically necessary care and integration of services. This way there is no interruption to the member’s care or prescription medications while striving to preserve the relationship between members and providers throughout the process.
Care Management staff will work with directly with members on facilitating coordination efforts by providers to assist the continuity and transition to other care when necessary. They will contact community agencies or make referrals to public assistance as appropriate and authorized by the member. They are also available to assist providers to coordinate appropriate services and programs available to members from such resources as:
- Care Managers
- Transportation and Interpreter Services
- Dental services
- Health Homes
- Regional Support Networks for mental health services
- Substance Use Disorder services
- Aging and Disability Services, including home and community-based services
- Skilled nursing facilities and community-based residential programs
- Department of Health and Local Health Jurisdiction services
Patient Review and Coordination (PRC) Program
Patient Review and Coordination (PRC) Program helps members use their medical services safely and appropriately.
Some members get care from several different doctors and use different pharmacies. They might use the emergency room a lot. They may have a high number of the same medications. When care is not coordinated, it can be dangerous. Sometimes we place these people in PRC because of these factors. Members must meet the criteria identified in WAC 182-501-0135 to be eligible for this program.
Members who are selected for PRC must choose one primary care provider, pharmacy, and hospital. If the member does not choose providers, we will choose them for the member. Members in PRC must go to these providers only. If a member in PRC goes to any other provider without a referral, the member must pay for the service.
One primary care provider makes sure medical care and prescriptions are coordinated for the health and safety of the member. PRC makes this possible. Members stay in the PRC program for at least 2 years as determined by state law.
Clinical Care Management Criteria and Guidelines
- Clinical Coverage Criteria (used to decide medical necessity)
- Clinical Practice Guidelines (used to determine treatment plan)
- Provider Manual
- Dialysis Notification Form
We follow these rules:
- Utilization Management decision makers approve or deny based only on whether the care and service are appropriate and whether the care or service is covered.
- CHPW does not reward providers or others for denying coverage or care.
- CHPW does not offer financial incentives to encourage Utilization Management decision makers to make decisions that result in under-using care or services.
Staff members are available to discuss the care management process, and appropriate peer reviewers (medical director, pharmacist, or associate clinical director) are available to discuss any management authorizations or denials. Relevant policies and/or clinical criteria are available upon request.
To contact our staff and peer reviewers, please call 1-800-440-1561 (TTY Relay: Dial 7-1-1), from 8:00 a.m. to 5:00 p.m., Monday through Friday.