- Utilization Management (UM)
We use evidence-based clinical practice guidelines when making decision about members’ care.
Clinical practice guidelines address preventive, acute or chronic and behavioral health services. These guidelines are reviewed at least every two years and updated as necessary. When this happens, we notify all network practitioners.
When determining the medical appropriateness of a service, we apply these criteria while considering individual circumstances and the local delivery system.
Clinical and UM staff make decisions based solely on appropriateness of care and existence of coverage. We do not reward staff for issuing denials of coverage. We do not encourage under utilization by providing financial incentives to deny coverage.
- Care Management
The Integrated Care Management (ICM) Program provides care coordination and health education for disease management, as well as identifies and addresses psychosocial barriers to accessing care with the goal of promoting high quality care that aligns with a Member’s individual health care goals. Care Management focuses on the delivery of quality, cost-effective, and appropriate health care services for Members. Members may receive health risk assessments that help identify physical health, behavioral health, medication management problems, and social determinants of health to target high-needs Members who would benefit from more intensive support and education from a case manager. Additionally, functional, social support and health literacy deficits are assessed, as well as safety concerns and caregiver needs.
- 1. The role of the Case Manager includes:
- Coordination of quality and cost-effective services.
- Appropriate application of benefits.
- Promotion of early, intensive interventions in the least restrictive setting of the Member’s choice.
- Assistance with transitions between care settings and/or Providers.
- Provision of accurate and up-to-date information to Providers regarding completed health assessments and care plans.
- Creation of ICPs, updated as the Member’s conditions, needs and/or health status change.
- Facilitation of Interdisciplinary Care Team (ICT) meetings as needed.
- Promote utilization of multidisciplinary clinical, behavioral and rehabilitative services.
- Referral to and coordination of appropriate resources and support services, including but not limited to Long-Term Services & Supports (LTSS).
- Attention to Member preference and satisfaction.
- Attention to the handling of Protected Health Information (PHI) and maintaining confidentiality.
- Provision of ongoing analysis and evaluation of the Member’s progress towards ICP adherence.
- Protection of Member rights.
- Promotion of Member responsibility and self-management.
- 2. Referral to Care Management may also be made by the following entities:
- Member or Member’s designated representative(s)
- Member’s Primary Care Provider
- Hospital Staff
- Home Health Staff
- SWH of MA staff
- Member Support Services
SWH of MA Member Services is available to help our members if they have any questions about their benefits and services.
- Member services staff are available Monday through Friday from 8 a.m. to 8 p.m. local time. Members can leave a voice message during non-business hours. We suggest our members leave a voice message with their question if it can wait until the next business day.
- SWH of MA offers free interpreter services to our members. As a provider, you are required to identify the need for interpreter services for your patients who are SWH of MA members and offer them appropriate assistance.
If members receive care from out-of-network providers without prior authorization, SWH of MA will not pay for this care. PCPs should contact us if they wish to request an exception referral for the member to see an out-of-network provider. If an out-of-network provider gives an SWH of MA member emergency care, the service will be paid.
Visit our Forms page for the most up-to-date list of services requiring prior authorization. Refer to the SWH of MA provider manual for more information about prior authorization.