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Medical management
The goal of our medical management team is to promote cost-effective care that helps members be as healthy as they can be. This means working with members and providers to assess conditions, create care plans, coordinate resources and check progress.
Contact us
To learn more about medical management, check your provider manual (PDF). Or call us at 1-844-365-4385 (TTY: 711). We’re here for you 8 AM to 5 PM, Monday to Friday.
Care management
Care management
Our goal is to improve access to quality care and avoid unnecessary medical costs. We help with the efficient use of medical resources for members with special health care needs, including complex, chronic and catastrophic cases.
We identify members who might benefit from care management through:
Utilization management activities
Health risk screenings
Review of administrative data
Our care management team supports members based on their personal health risks and unmet needs. We assign a care manager to each qualified member who agrees to take part in care management. As part of the medical management team, care managers help members connect with the services and care they need.
First, our care management staff screens members. Then, we use a biopsychosocial model to identify what care members need. Finally, the integrated care manager completes more health assessments. This determines the member’s medical, behavioral health and biopsychosocial status.
Care management programs include, but aren’t limited to:
Pregnancy outreach
Special health care needs
Behavioral health and substance use
Our care managers have a whole team behind them—the CCT. They work together to ensure whole health for members, including their:
- Physical health
- Behavioral health (includes mental health)
- Pharmacy access
In planning members’ care, we also keep other things in mind, like the conditions where they live, learn, work and play — the social determinants of health. These conditions can have a significant effect on health.
The CCT includes people who live and work in or near the communities they serve. Some team members include:
- Local care managers
- Clinical care managers who specialize in health topics like pregnancy and women’s health, behavioral health, substance use disorders, heart care and more
- Community health workers
- Community outreach staff
Aetna FamilyCare Central is our care coordination portal. Members, their care manager and those in their Care Circle can log in, get info and take action related to their plan.
Options for members
Inside Aetna FamilyCare Central, members can:
- Review documents like their care plans
- Look up their medicines
- See their claims and prior authorizations
- Show referrals to community organizations
- See and update appointments
- Check recommended preventive and wellness care
- Review their extra benefits
- Order a new ID card
- Message their care manager or Member Services
- Get notifications
- Find their care manager’s contact info
Keeping members’ health info together helps ensure we can align their goals with the services they get for physical and behavioral health.
We use tools like Aetna FamilyCare Central to make sure they get the best care possible. It gives them the info you need, when they need it.
Members and providers can contact us about care management. Members can self-refer. Or you can refer them:
- Call ${provider_services_phone}
- Email us
The state also offers personal care services for people who need help with the basics of daily living, like:
- Bathing and grooming
- Transfers to or from beds, chairs and more
- Toileting
- Preparing meals
- Shopping and errands
- Doing laundry
- Housekeeping
Chronic disease management
Chronic disease management
The chronic disease management program helps with regular communications, targeted outreach and focused education. We help members with specific conditions, like asthma and diabetes.
Members get education, coaching and other services to help them manage their condition. They also receive help from disease management nurses. These nurses perform health risk assessments. They can also create an action plan based on the member’s:
- Understanding of their condition
- Need for equipment and supplies
- Referral for specialty care or other special considerations due to comorbidities, including behavioral health and substance abuse
Utilization management (UM)
Utilization management (UM)
The purpose of UM is to manage the utilization of health care resources to ensure that members get the most medically appropriate and cost-effective health care. The goal of utilization management is to improve medical and behavioral health outcomes.
The UM team will help providers:
- Complete authorization requests submitted by fax or through the Provider Portal
- Review clinical guidelines and requests for peer-to-peer reviews
- Identify discharge plans for members leaving a hospital or facility
Quality management (QM)
Quality management (QM)
The main goal of our Quality Management program is to improve the health status of members. Our QM program uses multiple organizational components, committees and performance improvement activities to find opportunities for success. This allows us to:
- Assess current practices in both clinical and nonclinical areas
- Identify areas for improvement
- Select the most effective interventions
- Evaluate and measure the success of implemented interventions, refining them as necessary
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a widely used performance improvement tool. Visit our HEDIS page for more information.
We have a comprehensive ongoing Quality Assessment and Performance Improvement (QAPI) program that:
- Focuses on the quality of clinical care and services to our members
- Helps ensure that members get preventive health care in a timely manner
- Provides care management services to people with special health care needs
- Adheres to state and federal requirements
- Is overseen by the Governing Board of Directors and Quality Oversight Committees
Performance improvement and measurement are fundamental to the QAPI program. We can’t improve what we don’t measure, so we analyze encounter data to identify gaps in care and recommend opportunities for improvement. Your involvement, feedback and recommendations for improving the delivery of care and services are welcome. Just call us at ${provider_services_phone}.
Legal notices
HEDIS® is the property of the National Committee for Quality Assurance (NCQA).