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 chronic medical conditions.

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.

Pre-Certification of Selected Ambulatory Services
Subject to annual review and modification by HealthLink pre-certification of medical necessity is provided for the following services:

Pre-Certification of Selected Ancillary Services
Subject to annual review and modification by HealthLink, pre-certification of medical necessity is provided for the following services:

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 chronic medical conditions. Case Management helps the treating health care professional(s) help the patient achieve optimal and timely medical outcomes.

URAC Accreditation
HealthLink’s Medical Management program is fully accredited by URAC, and is registered according to applicable state regulations. URAC is nationally recognized as one of the preeminent accrediting boards for managed care organizations.

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.

Medical Management is part of the HealthLink Health Care Management Programs, an extensive suite of health promotion and wellness information, case management and care coordination services to help physicians help their patients achieve optimal health outcomes.