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Care Management: Helping Providers Assist Members

Date: 05/03/21

Early intervention is essential to maximize treatment options and minimize potential complications associated with illnesses, injury or chronic conditions. Superior HealthPlan’s Care Management team is available for members who may benefit from increased coordination of services, and to assist and support providers with member issues including non-adherence to medications/medical advice, multiple complex co-morbidities or to offer guidance with a new diagnosis. The Care Management team helps members:

  • Achieve optimum health, functional capability and quality of life through educating the member. This includes ensuring they have an understanding of their disease process, and tools to improve the management of their disease or condition.
  • Evaluate and assist members in accessing available benefits and resources.
  • Develop goals and coordinate with family, providers and community organizations to achieve these goals.
  • Facilitate referrals to appropriate providers or specialists.
  • Care coordination among multiple providers.
  • Connect with community resources.
  • Ensure timely receipt of appropriate services in the most appropriate setting.

Please review the table below for examples of member eligibility criteria for Superior’s Care Management services.

CARE COORDINATION

(followed by NON-CLINICAL STAFF / community health worker)

  • Members with psychosocial or social determinants of health issues such as:  
    • Food insecurity
    • Transportation set up
    • Health coaching for healthier lifestyle
    • Unstable housing or homelessness
  • Members needing non-clinical assistance such as:
    • Accessing medical equipment or supplies
    • Scheduling appointments with Primary Care Providers (PCP), specialists or other health-care services
    • Following up to ensure compliance
    • Facilitating referrals
    • Connecting with community resources
 

CARE MANAGEMENT

(followed by a LICENSED / CLINICAL STAFF – PHYSICAL OR BEHAVIORAL HEALTH supported by non-clinical staff /Communiity health worker)

Eligibility includes members who:

  • Have three or more unplanned inpatient (IP) admissions within the last six months (related to chronic conditions).
  • Have three or more preventable Emergency Room (ER) visits in the last three months (related to chronic conditions).
  • Have complex cases/multiple co-morbidities with acute exacerbation and/or unmet needs.
  • Are neonatal Intensive Care Unit (NICU) members at risk for non-compliance with medical care or treatment who have multiple medical diagnoses, with identified maternal risk factors.
  • Have new onset or unstable members with life sustaining device.
  • Have significant psychosocial issues/unmet needs that results or high risk for decompensation of health-care status or potential IP/ER utilization.
  • Are candidates for transplant or post-transplant within six months.
  • Have complex medical and behavioral issues that may result in ER/IP utilization.
  • Are high-risk pregnancy (history of preterm labor, members that are <60 days postpartum and have any medical complications).

Members can receive services over the phone, or through face-to-face visits in member’s home or in a provider’s office. Superior encourages providers and their staff to refer members, who may be facing complex medical issues, to the Care Management program. Members may also self-refer to this program.

Providers play an extremely important role in Superior’s Care Management program. If you have an Ambetter from Superior HealthPlan, Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) or CHIP member who would benefit from Care Management, please contact the Superior Care Management department:

  • To speak with a Care Manager, please call 1-855-757-6567.
    • Available to assist with coordination of the member’s health-care needs Monday through Friday, 8:00 a.m. to 5:00 p.m. (CST).
  • To submit a referral request, please visit the Referral tab in Superior's Secure Provider Portal.
  • To access a member’s information and/or their care plan, please visit the Patients tab in Superior's Secure Provider Portal.

For additional information, please visit the Superior Care Management webpage.

Please note: Superior adheres to the Case Management Society of America’s (CMSA) definition of Case Management as “a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes."