Medical Management Model

Utilization Management

Our Utilization Management (UM) program uses an integrated medical management model based on the physical, behavioral, and social needs of members. The UM program, in collaboration with other departments such as Care Management and Disease Management, facilitates the delivery of the most appropriate medically necessary care to members in the most cost-effective, least-restrictive setting.

Healthy Blue develops a predictive model that sorts members into levels of care by collecting individual data from:

  • Intake information
  • Historical claims data
  • Ongoing concurrent review

The level of care determines the level of intervention. This is targeted to conditions and episodes of care that have the most impact.

Care plans developed based on this information are specific to a member’s needs. Providers associated with the member are asked to help with development and execution of the plan so care is integrated across physical, behavioral, and social spectrums.

Care Management Model

Our member-centric care management model integrates behavioral, physical, and social factors into each individual member’s plan of care. Our model features the early identification of needs, continuous assessment of health, and a member home approach that promotes collaboration among members, family, service coordinators, providers, and community resources.

This approach to care management was specifically designed to meet the needs of Medicaid recipients.

To learn more about our Utilization Management program or our Care Management Model, please see your Provider Manual or contact your provider representative.

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