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 Blue HealthSolutions Care Management ProgramsOur case management program has been awarded Case Management Accreditation from URAC, a Washington, DC-based health care accrediting organization that establishes quality standards for the health care industry. Specialty Case Management About 20 percent of a health plan's members generate 80 percent of its claims. Our professional staff of in-house registered nurse case managers provides individual attention to members with chronic illnesses or catastrophic health events. Our doctors and nurses give members support and assist in coordinating the medical care that's most appropriate for their needs. The specialty case managers work as advocates, reviewing patients' conditions, providing comprehensive assessments of patients' knowledge, behavior and clinical status to optimize members' health care outcomes and identify other services and support systems available regionally. They act as advocates and even assist in arranging needed services, helping members get the most out of their benefits. Our case management program is voluntary and available at no additional cost to members of Blue Cross and Blue Shield of Vermont and The Vermont Heath Plan. We select members for case management through claims data or through referrals by physicians or other sources. >>> Find out more. Prior Approval and Other Review Our nurses and doctors conduct prior approval for a select list of tests, drugs and procedures known to be expensive and/or frequently misused (e.g., certain MRIs, home infusion therapy, etc.). We also use focused inpatient review and discharge planning for selected admissions to be sure they are in line with national (M&R) guidelines for medical necessity and appropriate length of stay. Some of our benefit programs (usually those that don't require physician referrals) require members to call for admission review before an admission (or in the case of an emergency or maternity stay, immediately following admission). We select certain types of admissions for review to be sure our members are getting the care they need, when they need it, in the most appropriate settings. |
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