Utilization management services are performed using industry-accepted medical criteria for appropriateness based on the specific condition or service. It is HealthLink's policy that a case not meeting the clinical criteria for the prescribing physician's treatment plan is immediately referred to a HealthLink physician reviewer or the Medical Director for review and follow-up with the prescribing physician. Clinical criteria are reviewed annually, at minimum, and are subject to approval by the Physician Advisory Committee and the HealthLink Medical Director. The committee validates the current status and appropriateness of the criteria.

Any case not meeting standard medical practice guidelines is referred to a physician advisor or the Medical Director. Physician review and consultation with the treating provider may occur when treatment patterns fall outside practice guidelines.

Staff Qualifications
The case management staff consists of licensed registered nurses who have completed a formal orientation program. Each nurse has a minimum of five years of clinical nursing in addition to case management experience. Case manager orientation is a 12 week program, followed by a probationary period during which further orientation may take place if needed. All case managers are audited regularly for adherence to the CompManagement Program policies and procedures.

The HealthLink CompManagement Medical Director oversees the processes in the CompManagement department and the management of claims files, including utilization of services and communication with network providers.

Access
The HealthLink CompManagement department is open from 8:00 a.m. to 5:00 p.m., CST on business days. A voice mail system is available for messages outside business hours. A toll-free number is available and all messages are returned within 24 hours or the next working day of receipt.

Medical Case Management Services
HealthLink’s CompManagement program focuses on providing quality cost effective medical care to enable injured employees to return to work in a safe, timely fashion.

Procedures:

• The insurer, the employer or the provider, via telephone or fax, notifies HealthLink CompManagement's Case Management of an employee injury.
• Compensation is verified through the claims adjuster and contacts are made with the treating provider, the injured worker, and the employer.
• Case managers evaluate the injury, develop a plan, and assess the effectiveness of that plan by working with the treating provider, employee and employer. Routine reports are made to the adjuster to ensure the proper benefits are processed in a timely manner and within state statutes. An estimated length of disability is determined and reported to the insurer.
• Case management activities continue throughout the duration of medical treatment and ceases when the employee has been released from care or the provider determines that the injured worker has reached maximum medical improvement.