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  • Care Management > Case Management

    Overview

    EmblemHealth's Case Management program assesses, plans, implements, coordinates, monitors and evaluates benefit options and services to meet member's health care needs. The Case Management program also has an educational component to ensure members understand their health conditions and the impact those conditions have on their daily lives.

    The EmblemHealth Case Management program is a member-centric approach to supporting the member's self management in their journey to wellness. EmblemHealth supports this member-centric approach to case management and utilizes a multidisciplinary team to support all aspects of the member's needs. As part of an interdisciplinary team, the member's primary care physician helps to determine the health care needs of the member in collaboration with nurses, case managers, social workers, physicians and ancillary support staff.

    We offer the following specialty case programs to assist clinicians in meeting the complex needs of their patients:

      Frail and Elderly Case Management

      This program supports the care needs of frail and elderly individuals in Medicare and special needs plans by helping them maximize their benefits and providing resources that help keep them in their communities.

      The goals of the program include:

      • Maximizing the functionality and independence of frail elder adults living in the community
      • Facilitating the delivery of health care services in the most appropriate setting

        The processes for referring and being involved in this case management program are as follows:

        1. Physicians and/or members may refer Medicare members to the program.
        2. Case managers will contact members telephonically to explain the program and its benefits.
        3. Upon the member's agreement, the member is enrolled in the program.
        4. A team consisting of a case manager and a social worker performs a telephonic assessment designed to identify the member's needs.
        5. After the assessment, an individualized plan of care is developed to meet any care gaps or needs the member may have.
        6. Notification by letter is sent to the PCP to ensure the PCP is aware that the member is enrolled in the case management program.
        7. Ongoing monitoring of the member's status and plan of care is performed to address any changes in the member's medical condition.
        8. Ongoing communication with the PCP and other health care disciplines is established to ensure that support for services needed by the member occurs.

        The case manager and social workers' functions are to:

        • Coordinate the member's health care services
        • Educate members regarding their health (e.g., chronic medical conditions, home safety, aging processes, correct use of medications)
        • Serve as liaisons between the member, physician and other members of the health care team
        • Make referrals to community resources (e.g., senior centers, meals-on-wheels, home attendant and transportation services and entitlement programs)

          To make a referral to this program or for more information, please call 1-800-447-0768 or the managing entity listed on the member's ID card.

          Government Programs Case Management

          Government Programs Case Management focuses its efforts on Medicaid children and members who have an acute exacerbation of chronic conditions in addition to catastrophic injuries. The goal is to help members understand their conditions for their optimal management. The interdisciplinary team of nurses and social workers work to coordinate members' health care needs, support educational needs, and promote home and community-based services through access to local, state and federal agencies.

          To request these case management services for Medicaid members, providers and members may call us at 1-800-447-0768.

          HIV/AIDS Case Management

          By collaborating with the member and the member’s health care team, EmblemHealth’s HIV/AIDS case management program helps members living with HIV/AIDS to self-manage their disease and health care needs.

          In an effort to improve care and treatment adherence, the HIV/AIDS case manager:

          • Assesses medication compliance
          • Assesses viral load and CD4 counts
          • Assesses compliance with the prescribed treatment plan
          • Assists with referrals to HIV specialists and New York State-designated AIDS treatment centers
          • Provides educational material to clinicians and members

            The department is staffed by a registered nurse and supported by a medical director and a pharmacist.

            Learn more about our HIV/AIDS case management program. To request HIV/AIDS case management services, members or providers may call us at 1-800-447-0768.

            Neonatal Case Management

            EmblemHealth offers a program to address the needs of newborns that have had difficulties at birth. Neonatal intensive care unit (NICU) nurse case managers monitor the progress of the newborn confined to the NICU. These nurses work with the attending neonatologist and EmblemHealth case managers to coordinate and facilitate a safe and supportive hospital discharge plan that meets the needs of the baby and the family.

            To request neonatal case management services, members and providers may call 1-800-447-0768.

            Transplant Program Case Management

            EmblemHealth's transplant program manages members with health care needs associated with having or preparing for a solid organ or bone marrow transplant. All transplant services are reviewed with the medical director assigned to support the transplant case management program. All requested transplant services are reviewed for medical necessity and evidence-based criteria are utilized to support the best care coordination and outcomes for EmblemHealth transplant members.

            To request transplant case management services for the EmblemHealth transplant program, members and providers may call 1-800-447-0768.

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            Glossary terms found on this page:

            Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

            A program that assists the patient in determining the most appropriate and cost-effective treatment plan, including coordinating and monitoring the care with the ultimate goal of achieving the optimum health care outcome.

            An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

            • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
            • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
            • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
            • Maintains medical records for all patients
            • Has a requirement that every patient be under the care of a member of the medical staff
            • Provides 24-hour patient services
            • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

            A card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.

            The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.



            Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

            A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

            A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.

            A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

            An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

            A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

            A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

            A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a PCP.

            A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

            • Doctor of medicine
            • Doctor of osteopathy
            • Dentist
            • Chiropractor
            • Doctor of podiatric medicine
            • Physical therapist
            • Nurse midwife
            • Certified and registered psychologist
            • Certified and qualified social worker
            • Optometrist
            • Nurse anesthetist
            • Speech-language pathologist
            • Audiologist
            • Clinical laboratory
            • Screening center
            • General hospital
            • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

            A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

            A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

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