Medical Management Key Features
- Toll-Free Customer Service
- Appeals Process
Utilization Management
- URAC-Accredited
- Pre-Admission Certification of Planned Hospital Admission
- Notification of Emergency Hospital Admission
- Concurrent Hospital Stay Review
- Discharge Planning
- Services Requiring Pre-Certification
Case Management
- Supports individuals with chronic or catastrophic conditions
- Helps achieve optimal, timely outcomes
HealthLink Medical Management offers state-of-the-art technology and a single cost management
platform across network programs. Medical Management is a component of HealthLink’s comprehensive
Health Care Management Program. Clients may include any or all Medical Management components
or they may opt out of the program, depending on particular pre-certification requirements.
HealthLink’s Medical Management program is comprised of Utilization Management and Case
Management. Utilization Management provides medical necessity review for proposed or concurrent
medical care to help clients determine benefit eligibility in accordance with health benefit
plan provisions. Case Management supports individuals with catastrophic or high-cost medical conditions.
Utilization Management
Medical necessity review recommendations are not medical treatment decisions, and no patient-practitioner
relationship exists between the HealthLink clinical reviewer and the health plan enrollee.
In addition, medical necessity recommendations are not benefit determinations. Benefits
are determined according to the provisions of the applicable health plan, and the plan
administrator retains authority with respect to eligibility, coverage and benefits under
the plan. Utilization Management components include:
Pre-Admission Certification of Planned Hospital Admission
Pre-admission medical necessity certification is required for all planned inpatient admissions
with the exception of maternity cases. This component lets HealthLink know that a patient
will be admitted to a hospital. The medical necessity of hospitalization is reviewed
according to outcomes-based peer reviewed standards and criteria for hospital admissions.
Mothers and infants hospitalized for more than three days for vaginal delivery, or
more than five days for cesarean section, will receive concurrent review services.
Notification of Emergency Hospital Admission
In the event of an emergency admission, HealthLink is notified by the hospital, attending
physician, patient or patient’s representative the next business day after admission.
Concurrent Hospital Stay Review
Concurrent hospital stay review is conducted during the course of a hospitalization. Length
of stay is reviewed by facility and according to diagnosis.
Discharge Planning
HealthLink coordinates communications regarding discharge planning with physicians, hospital
nurses and social service organizations, as needed.
Services Requiring Pre-Certifi cation
HealthLink’s Utilization Management program is designed to provide clinical review of medical care to convey information and
recommendations to plan administrators and carriers in connection with their determination of benefi t eligibility. Medical necessity
certifi cation does not guarantee that services are covered. Benefi ts are subject to the patient’s eligibility at the time charges are actually
incurred, and to all other terms, conditions and exclusions of the applicable health plan.
Inpatient Services (Medical, Surgical, Behavioral)
- Bariatric Surgery
- Elective Admissions
- Emergency Admissions
- Hospice
- LTAC Admissions
|
- Lumbar Spine Surgery
- Rehabilitation Facility Admissions
- Skilled Nursing Facility Admissions
- Transplants
|
Surgical Procedures - Ambulatory
- Bariatric Surgery
- Cartilage Transplant Knee
- Lumbar Spine Surgery
- Nasal Septoplasty
|
- Rhinoplasty
- Sinus Endoscopy
- Sleep Apnea Surgery - LAUP/UPPP, Nasal,and Uvulopalatoplasty
|
Ancillary Services
- Home Infusion Services
- Home Health Services
- Home Hospice
|
- Occupational Therapy
- Physical Therapy
- Speech Therapy
|
Durable Medical Equipment
- Bone Stimulator
- Cardio/External Defibrillator
- Cochlear Implant
- Cooling Devices (i.e. Polar Care)
- CPAP/BIPAP
- Electric Scooters
- Functional Electrical Stimulator Bikes
|
- Limb Prosthetics
- Myoelectric prosthetics
- Neuromuscular Stimulators
- TENS Unit
- Wheelchairs (Custom)
- Wheelchairs (Power)
- Wound Vacs
|
Diagnostic Imaging - Ambulatory
- MRA of the Head and/or Neck
- MRI of the Brain
|
- MRI of Spine – Cervical, Thoracic, Lumbar, Sacral
- PET Scans
|
Case Management
HealthLink’s Case Management program is a collaborative process among HealthLink and other health professionals who manage the
resources necessary to support individuals with catastrophic or high-cost medical conditions. Case Management helps the treating health
care professional(s) help the patient achieve optimal and timely medical outcomes.
Customer Service
The Medical Management Customer Service Call Center is open from 8:00 a.m. to 5:00 p.m.
CST each working day. A toll-free voicemail system is available for messages outside
of business hours. All messages are returned the next working day after receipt.
Medical Management Appeals Process
HealthLink contracted physicians, hospitals and other health care professionals have the right to appeal adverse medical necessity
recommendations. Reconsiderations may be handled on a standard or expedited appeal basis and are reviewed by clinical professionals
not involved in the original decision. Requests for clinical rationale and/or appeal may be made by the physician, hospital, patient or
patient representative. The initial adverse medical necessity recommendation may be overturned or upheld by the physician reviewer.
HealthLink’s medical necessity recommendation is not a benefit determination; the plan sponsor has the final authority with respect to
whether plan benefits are available.
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