Utilization Management

When a patient is undergoing treatment for an acute or chronic condition such as cancer, it often takes an effort to make sure that she or he gets the appropriate care. Many chronic conditions require treatment from multiple facilities and entities, and individuals would find the process to be overwhelming. That is why managed care entities such as Paramount use case management for members with serious conditions who need a lot of resources. Our goal is to make sure that services are delivered accurately—and that our members get the most out of the resources that are available to them.

The case manager is an advocate for the member’s health and well-being. Case managers work closely with members to provide education on how to manage their conditions. Case managers may speak with the member in an acute care setting, after hospital discharge, in a home care environment, or in an ambulatory care setting. One of the aims of case management is to get the individual and caregiver involved in the decision-making process, so that they understand the many facets of the health care they need, and they receive the necessary treatment.

• Treatment of the member in the least restrictive setting and manner
• Improvement of self-management of disease and condition
• Increase in member satisfaction
• Return of the member to his or her maximum potential
• Support for the Primary Care Physician (PCP)
• Utilization of participating providers
• Reduction in the cost of care
• Reduction of unplanned hospital admissions and inappropriate emergency room usage.
• Education of member regarding disease process

Do you have questions about case management at Paramount? Please feel free to call the Utilization/Case Management Department at 419-887-2520 or 800-891-2520.

Paramount’s belief in patient safety and well-being extends to our policy concerning emergency room services for our members. No referral is ever required for treatment of an emergency medical condition. How do we define an emergency medical condition?

An emergency medical condition manifests itself by acute symptoms of sufficient severity (including severe pain). In a medical emergency, a prudent layperson with an average knowledge of health and medicine could expect the following to happen if they did not seek medical attention:

• The health of an individual (or, with respect to a pregnant woman, the woman’s health, and that of her unborn child) would be placed in serious jeopardy.
• Bodily functions would be seriously impaired.
• Any bodily organ or part would suffer serious dysfunction.

Paramount's Inpatient Hospital Certification process is designed to make sure that all hospital admissions are medically appropriate and that the care given to our members is being provided in the correct setting. To determine whether the care is appropriate, we use InterQuals' Level of Care criteria, along with clinical judgement. These criteria also help us assess the medical necessity of continued stay for our members. Do you have questions about the criteria that we use to establish medical necessity? Our providers are always encouraged to contact the Utilization Management Department at 419-887-2520 or 800-891-2520 for more information about inpatient hospital certification.

During an inpatient hospital stay, Paramount's transition of care team will assess post stabilization needs. Appropriate services will be arranged through participating providers.

Occasionally, you may wish to refer a patient to a specialist or facility that is outside of our network of providers. All out-of-Plan referrals require prior authorization (PA), and we make PA decisions based on the patients medical needs and the availability of services to meet these needs within the provider network. Every case is reviewed on an individual basis.

If you would like to make an out-of-plan referral, please contact the Utilization Management Department at 419-887-2520 or toll free at 800-891-2520. Your office may instead choose to fax out-of-plan referral requests. If you would like to fax an out-of-plan referral request, fill out the out of plan prior authorization form and fax it to the Utilization Management Department at 1-567-661-0847.

A fundamental component of the utilization management process occurs after care is given. This process is known as retrospective analysis and its goal is to evaluate how effective the services were. During retrospective analysis, patient care data is meticulously analyzed. Some of the factors that are considered are medical necessity, the quality of care, and the appropriateness of the medical setting. This data is then compared with other data sets so that we can identify patterns in the health care services of institutions and physicians and in how our members use health care services.

If you would like to know more about the role that retrospective analysis plays in our utilization management program, please see our Utilization Management Program Description.

When your patient needs to see an in-plan (participating) specialist, they are able to do so freely without prior authorization or any extra administrative steps. You may refer your patients to a participating specialist at any time.

Other prior authorization policies remain in effect. If you have any questions about specialist referral policies, please feel free to contact the Utilization Management department at at 419-887-2520 or 800-891-2520.

Sometimes, your patients will require the kind of complex consultative care that only a tertiary care facility can provide. In those cases, you may wish to make a referral to a tertiary care center. All referrals to tertiary care centers are reviewed on an individual basis. When we review these referrals, we mainly consider the member's medical needs and whether the requested services are available in the non-tertiary care network.

To make a referral to a tertiary care center, please have your office call the Utilization Management Department at 419-887-2520 or 800-891-2520. Your office may also choose to fill out the out-of-plan referral worksheet and fax the completed request to the Utilization Management Department at 419-887-2028.