Right Care, Right Time,
- SNP Model of Care
- Cost Containment
- Mental Health Parity
- Care Management Integration
- Programs & Services
- Population Health
- Integrated Case Management
- Synergy Targeted Population Management®
- :: Identify
- :: Engage
- :: Connect
- :: Empower
- :: Impact
- Medical Management
- Behavioral Health Management
We understand that Medical Management is not meant to be a vehicle for denying services, but is best used to ensure that the right care is delivered at the right time, at the right place for the benefit of members. Effectively delivered, it can produce significant savings while improving overall quality.
Our Medical Management services are supported by our integrated view of health management, leading-edge technology platform and a dedicated team of experienced healthcare professionals. Built on years of experience, including complex cases involving coexisting medical and behavioral conditions, these services can be implemented on either Health Integrated’s technology platform or on our client’s system, if that’s determined to be a more beneficial approach.
Health Integrated’s Utilization Management team eliminates non-essential treatments and keeps individuals on the path to health by closely monitoring prescribed procedures for medical necessity. Our expert nurses and clinicians work with care providers and plan managers using detailed patient history information, national medical protocols and medical necessity criteria. In addition to coordinating approvals for treatment, our team follows up to coordinate continuing or outpatient care after discharge and makes referrals to Case Management where appropriate. Our Utilization Management program is NCQA certified and URAC accredited.
Physician Review Services
Complementing Utilization Management, Health Integrated also offers Physician Review Services. In the instance when a Utilization Management nurse has difficulty reaching a determination of medical necessity, our medical directors are available for additional support, including denials and appeals.
As part of these review services, providers may request a written statement of the
clinical rationale, including the criteria, policy and/or procedure used in making
a medical necessity determination. This information will be available upon request
at no additional charge.
» Request Criteria
Health Integrated provides dedicated coordination for involved medical cases. Our Case Managers advocate on behalf of the member to ensure that their treatment is followed and can identify unspecified physical health needs or behavioral health issues. We can customize the case identification approach to customer specifications. By operating across multiple organizations, plan programs and benefit providers, our Case Managers ensure awareness of the member’s status, authorizations and care plan. Our Case Management program is URAC Accredited.
Nurse Advice/Triage Services
Health Integrated’s Nurse Advice/Triage Service is a comprehensive assessment and education program administered by licensed nurses that provides members with accurate health information to support informed healthcare decision-making.