Medical Case Management Program

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 an individual get the most benefit from the plan without compromising the quality or integrity of care. During the course of this process, an individual 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 medical review agency to examine medical records and determine if an individual’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 an individual 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 or medications. The plan has the right to deny payment for any services received outside of the required case management program. The individual has the right to appeal the plan’s determination and the required case management plan through the appeals procedures described in this booklet (please see Claims and Appeals Rules).

In all situations, the plan reserves the right to reduce or deny benefits if certain ongoing care is determined medically unnecessary or inappropriate for the individual’s condition.