Name of Manual - Blue Cross and Blue Shield of Minnesota

Chapter 4
Integrated Health Management
Table of Contents
Integrated Health Management................................................................................................ 4-3
Introduction............................................................................................................................4-3
Objectives ..............................................................................................................................4-3
Provider Contractual Obligations – Important Program Points............................................. 4-4
Integrated Health Management Decision Making .................................................................4-5
Utilization Management ............................................................................................................ 4-6
Purpose................................................................................................................................... 4-6
Goals ...................................................................................................................................... 4-6
Integrated Health Management Medical and Behavioral Health Clinical Staff ....................4-7
Medical Policy ............................................................................................................................ 4-8
Medical and Behavioral Health Policy Development............................................................4-8
Medical Policy and Behavioral Health Policy Manual.......................................................... 4-9
Prior Service Request Form................................................................................................. 4-10
High Technology Diagnostic Imaging Decision Support...................................................... 4-11
Overview..............................................................................................................................4-11
Pre-Certification/Authorization ............................................................................................. 4-14
Overview..............................................................................................................................4-14
Scope and Purpose ...............................................................................................................4-15
Decision Making and Notification Time frames ................................................................. 4-16
Definition of Urgent Request...............................................................................................4-17
Services Requiring Pre-Certification Utilization Management Pre-
Certification/Authorization Requirements............................................................................ 4-19
Overview..............................................................................................................................4-19
Inpatient & Residential Pre-Service Admission Requirements........................................... 4-19
Out-of-area Blue Plan Patients............................................................................................. 4-19
For Local Blue Cross Plan Patients ..................................................................................... 4-19
Where to Send Requests..........................................................................................................4-21
Inpatient Admissions ........................................................................................................... 4-21
Inpatient Pre-Certification/Authorization Requests.............................................................4-21
Appeals ................................................................................................................................4-22
On-site Concurrent Review..................................................................................................4-22
Compliance Audit .................................................................................................................... 4-23
Overview..............................................................................................................................4-23
Case & Disease Management.................................................................................................. 4-24
Overview..............................................................................................................................4-24
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-1