Medical management

We use several sources to identify members for care management and disease management: 

• Enrollment data from the state 
• Predictive modeling tools 
• Claim/encounter info, including pharmacy data, if available 
• Data collected through the utilization management process 
• Lab results 
• Hospital or facility admissions and discharges
• Health risk appraisal tools 
• Data from health management, wellness or health coaching programs 
• Provider referrals for members who act inappropriately or are disruptive or threatening in the office 

 

Once these members are identified, they are then assessed by our licensed: 

• Nurses 
• Social workers 
• Counselors 
• Nonclinical professionals 

 

Afterwards, we use a biopsychosocial model to identify what care members need. Finally, the care manager will do a health risk assessment. This determines the member’s medical, behavioral health and biopsychosocial status. 

We can help your patients with certain conditions enhance their self-management skills. This includes conditions like:

• Asthma
• Diabetes
• Chronic obstructive pulmonary disease (COPD)
• Hepatitis C
• Other conditions

Care management programs may also include topics like:

• Pregnancy outreach and high-risk obstetrics (OB)
• Special health care needs 
• Behavioral health and substance abuse

Care managers educate members about their condition and how to prevent worsening of their illness or any complications. The goal is to maintain, promote or improve their health status. 

To create a quality-focused, cost-effective care plan, care managers collaborate with:

• The member
• Member’s family
• Primary care provider 
• Psychiatrist
• Substance abuse counselor
• Other health care team members

To identify members that are the right fit for care management, we may use referrals from:

• Our health info or special needs lines
  
• Members
• Caregivers
• Providers
• Practitioners 

Integrated care management means your patient only has one care manager, even if they also take part in:

• Care management
• Condition management

Learn more about care management

Our care managers can offer special attention to members who have a high-risk pregnancy. Members can get support for a healthier pregnancy, including info about preterm labor and birth.  

Do you have a patient who’s pregnant?

Be sure to complete and submit the notice of pregnancy form (PDF). This will help us to identify if your patient has a high-risk pregnancy. We’ll then connect them to the care and services they need. 

You can submit the form in one of two ways: 

• Complete the form and fax it to: 1-866-776-2813, Attention: Care Management  
• Call Provider Relations at 1-855-242-0802 (TTY: 711)  for help submitting the form

You can learn more about our UM criteria at these links.

Negative Pressure Wound Therapy (NPWT) (Wound VAC) Louisiana Policy (PDF)

Chiropractic In Lieu of Services Policy (PDF)

BRCA 1 and 2 Gene Testing and Genetic Counseling Policy (PDF)

Continuous Positive Airway Pressure (CPAP) Policy (PDF)

Bariatric Surgery and Pannulectomy Policy (PDF)

CPT Vest-High Frequency Chest Policy (PDF)

Peer Support Services Policy (PDF)

Assertive Community Treatment (ACT) Services (PDF)

Substance Use Disorder Treatment- Intensive Outpatient and Residential Levels of Care (PDF)

Pediatric Day Health Care (PDF)

Crisis Stabilization Services for Adults (PDF)

ASAM Determination Grid (PDF)

ASAM Scroing Guide (PDF)

Applied Behavior Analysis (PDF)

Peer Support Services (PDF)

Community Brief Crisis Support (CBCS) and Behavioral Health Crisis Care (BHCC) (PDF)

Personal Care Services- Behavioral Health (PDF)

Crisis Intervention (CI) Services (PDF)

Multi-Systemic Therapy (MST) (PDF)

Community Psychiatric Support and Treatment (CPST) and Psyc (PDF)

Mental Health Intensive Outpatient (PDF)

Assertive Community Treatment (ACT) Services (PDF)

National Comprehensive Cancer Network

MCG Health authorization criteria provider search — general  

MCG Health authorization criteria provider search — specific criteria 

Medical clinical policy bulletins (CPB) search 

Clinical policy bulletins 

Provider manual (PDF)

Louisiana Department of Health (LDH) applied behavior analysis provider manual (PDF)

LDH behavioral health services provider manual (PDF)

LDH general provider manuals

Member handbook (PDF)

Member handbook for mental health and substance use treatment services (PDF)

Child and Adolescent Level of Care Utilization System (CALOCUS) — evaluation parameters (PDF)

CALOCUS — worksheet (PDF)

Level of Care Utilization System (LOCUS) — level of care determination grid (PDF)

LOCUS — scoring sheet (PDF)

LOCUS — Levels Care Handout (PDF)

We base our utilization management (UM) decisions on appropriateness of care and service, subject to covered benefits. If we contract with practitioners and providers to make UM decisions, we require that they make decisions based only on appropriateness of care and service. 

We don’t provide incentives or make financial arrangements that encourage staff or contracted providers making UM decisions to:

• Issue denials, limitations or discontinuation of medically necessary care 
• Make decisions that lead to underutilization  

This includes our policies and practices in: 

• Hiring
• Compensation
• Termination
• Promotion
• Any similar matters