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Care Management: Helping Providers Assist Superior Members

Date: 06/03/24

Early intervention is crucial for effective healthcare management. Superior HealthPlan’s Care Management team is here to assist our Superior Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP and Ambetter from Superior HealthPlan members. This team helps minimize potential complications associated with illness, injuries, or chronic conditions by offering increased assistance with services through Care Coordination or Care Management. Superior’s Care Management team is equipped to help 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 provides comprehensive support to our Superior members by:

  • Achieving optimum health, functional capability and quality of life through education. This includes ensuring the understanding of disease processes and providing tools to improve the management of a disease or condition(s).
  • Evaluating needs to ensure access to available benefits and resources.
  • Developing goals and coordinating with family, providers, and community organizations to achieve these goals.
  • Facilitating referrals to appropriate providers or specialists.
  • Coordinating care among multiple providers.
  • Connecting members to community resources.
  • Ensuring timely receipt of appropriate services in the most appropriate setting.

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

Care Coordination (provided by Non-Clinical Staff/Community Health Worker):

  • Eligibility includes members with psychosocial or non-medical drivers of health, such as: 
    • Food insecurity.
    • Transportation needs. 
    • Unhealthy lifestyle, needing health coach assistance.
    • Unstable housing or homelessness.
  • Eligibility includes members needing non-clinical assistance such as:
    • Accessing medical equipment or supplies.
    • Scheduling appointments or other health care services with Primary Care Providers (PCPs) or specialists.
    • Following up to ensure timely completion of provider appointments.
    • Facilitating referrals to appropriate providers or specialists.
    • Connecting with community resources.

Care Management (provided by licensed/clinical staff – physical or behavioral health supported by non-clinical staff /community health worker):

  • Eligibility includes members who have any of the following:
    • Three or more unplanned inpatient (IP) admissions within the last six months related to chronic conditions.
    • Three or more preventable Emergency Room (ER) visits in the last three months related to chronic conditions.
    • 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.
    • New onset or unstable members with life sustaining device.
    • Significant psychosocial issues/unmet needs that are at high risk for decompensation of health-care status or potential IP/ER utilization.
    • Are candidates for transplant or post-transplant within six months.
    • 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).

If a member meets the needs of the eligibility criteria listed above, they can easily access Care Coordination or Care Management services. These services are available over the phone or through face-to-face visits in a member’s home or provider’s office. Members may self-refer to this program by calling the Member Services number on the back of their member ID card. We encourage providers and their staff to refer members who may be facing complex medical issues to this program, emphasizing the ease of access to our services.

If you have a patient who is a Superior member and would benefit from our Care Management program, please don’t hesitate to get in touch with our dedicated Care Management team. They are ready to assist you and the members in navigating the healthcare system and ensuring the best possible care.

Providers can contact our Care Management team as follows:

  • To speak with a Care Manager, please call 1-855-757-6567.
    • Care Managers are available to assist with the coordination of a member’s healthcare needs Monday - 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 Superior's 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."