6.9 CASE MANAGEMENT
Case Management is administered by the Utilization Management Organization. The Utilization Management Organization’s medical professionals work with the patient, family, care-givers, Health Care Providers, and the Administrative Office to coordinate Plan coverage of a treatment program. Case Management services are particularly helpful when the patient needs complex, costly, and/or high-technology services. Case Management may authorize coverage of specific care that would not otherwise be a covered benefit under the Plan if it appears that such alternate care will offer a cost-effective result without a sacrifice to the quality of your care.
Case Management, the patient and the attending provider must all agree to the alternate care. The decision to provide alternate care will be made by Case Management in its sole discretion on a case by case basis pursuant to this section. Such a decision shall not be construed to alter or change other provisions of the Plan, nor shall it be construed as a waiver of the right to otherwise administer the Plan in strict accordance with its terms.
Working with the Case Manager
You can request Case Management services by calling the Utilization Management Organization. In most cases, the Utilization Management Organization will initiate Case Management services automatically. The Utilization Management Organization’s Case Manager will work directly with you to review proposed treatment plans and to assist in coordinating services and obtaining discounts as needed. From time to time, the Case Manager may confer with your Physician and may contact you or your family to assist in making plans for the Plan to cover continued health care services, and to assist you in obtaining information to facilitate coverage of those services.
You, your family, or your Physician may call the Case Manager at any time to ask questions, make suggestions, or offer information.