2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 38
Concurrent Inpatient Review
Once the inpatient setting has been precertified, the on-going review of the course of treatment becomes the focus
of the program. Working directly with your Physician, the Medical Management and Precertification Program
Administrator will identify and approve the most appropriate and cost-effective setting for the treatment as it
progresses.
To File a Complaint or Request an Appeal to a Non-Certification
Verbal appeal requests and information regarding the appeal process should be directed to the Medical
Management and Precertification Program Administrator as identified on the General Plan Information page of this
Medical Plan.
Case Management
When a catastrophic condition, such as a spinal cord injury, cancer, AIDS or a premature birth occurs, a person
may require long-term, perhaps lifetime care. After the patient’s condition is diagnosed, the patient might need
extensive services or might be able to be moved into another type of care setting, even to the patient’s home.
Case management is a program whereby a Case Manager contacts the patient to obtain consent for case
management services. The Case Manager monitors the patient and explores, discusses and recommends
coordinated and/or alternate types of appropriate medical care. The Case Manager consults with the patient, family
and the attending Physician in order to develop a plan of care for approval by the patient’s attending Physician and
the patient.
This plan of care may include some or all of the following:
(1)
Personal support to the patient;
(2)
Contacting the family to offer assistance and support;
(3)
Monitoring Hospital or skilled nursing care or home health care;
(4)
Determining alternate care options; and
(5)
Assisting in obtaining any necessary equipment and services.
Case management occurs when this alternate benefit will be beneficial to both the patient and the Medical Plan.
The Case Manager will coordinate and implement the case management program by providing guidance and
information on available resources and suggesting the most appropriate treatment plan. The Medical Plan staff,
attending Physician, patient and patient’s family must all agree to the alternate treatment plan.
Case management is a voluntary service. There are no reductions of benefits or penalties if the patient and family
choose not to participate.
Each treatment plan is individually tailored to a specific patient and should not be seen as appropriate or
recommended for any other patient, even one with the same diagnosis.
Medical Management will not interfere with your course of treatment or the Physician-patient relationship. All
decisions regarding treatment and use of facilities will be yours and should be made independently of this Program.
The Medical Management and Precertification Program Administrator contact information for this Medical Plan is
identified on the Employee insurance card and also on the General Medical Plan Information page of this Group
Health Plan.
Meritain Health 24x7 Nurse Line
The Medical Plan provides coverage for telephonic medical advice provided by specially trained registered nurses
for non-emergent care. Common examples of when to use the Meritain Health 24x7 nurse line for non- emergent
medical care include but are not limited to the following: medical advice after office hours; care while on vacation;
and research and advice on a particular health conditions, lifestyle choices or self-care strategies.
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