2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Care Coordination6. Care Coordination6. Care CoordinationCare coordination exists to support you and yourPresbyterian patients. We are here to assist youwith coordination of care and services for yourpatients with chronic or catastrophic illnesses andinjuries and in promoting healthy lifestyles.Care coordination also serves to provide you andyour Presbyterian patients with proactive tools andresources to help them improve their health, stayhealthy, and live with chronic disease byAssisting providers and members to preventor reduce the burden of diseaseAssisting individual members with accessingmedical and behavioral health careIdentifying health needs and risksImproving the health of member populationswith selected health conditionsAssisting members to obtain appropriatemedicationsPredicting and managing health care costsFacilitating appropriate and cost-effective careEnsuring privacy and confidentiality of medicalinformationPresbyterian’s Utilization Management (UM)program includes care coordination for theevaluation of the appropriateness, medical need,and efficiency of health care services proceduresand facilities, according to established criteria andguidelines. Care coordination UM processescomprise a comprehensive set of integratedcomponents including prior authorization,concurrent review, continued stay review,retrospective review, discharge planning, andindividual medical case management as required todetermine medical necessity.The National Committee for Quality Assurance(NCQA) affirmative statement about incentives forUM decision making requires that “The organizationdistributes a statement to all members and to allpractitioners, providers, and employees who makeUM decisions, affirming the following:1. UM decision making is based only onappropriateness of care and service andexistence of coverage.2. The organization does not specifically rewardpractitioners or other individuals for issuingdenials of coverage.3. Financial incentives for UM decision makers donot encourage decisions that result inunderutilization.”Coordinating Care: Prior AuthorizationReferralsFor Commercial, Presbyterian Senior Care HealthMaintenance Organization, and selectAdministrative Service Only (ASO) plans, the modelis “no referral required” for most care rendered bycontracted specialists. This includes referrals from6-12014 Practitioner and Provider Manual - Ver. 3