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UM CM Terms

Terminology for UM CM

TermDefinition
CHIP Program designed for families wo earn too much money to qualify for Medicaid, yet cannot afford to buy private insurance for their children
TANF Program that provides assistance and work opportunities to needy families by granting states the federal funds and wide flexibility to develop and implement their own welfare programs. Citizens may apply for assistance at their local Temporary Assistance for Needy Families (TANF) Agency.
EPSDT A Federally-mandated health program for Medicaid recipients under age 21. Designed to identify physical and mental defects and to provide treatment to cover or ameliorate defects and chronic conditions.
Supplemental Security Income A federally income supplement program funded by general tax revenues (not Social Security taxes) designed to help aged, blind, and disabled persons who have little or no income and to provide care to meet basic needs for food, clothing, and shelter.
Utilization Management This is a program that ensures eligible members receive the most clinically appropriate services in the most efficient manner possible, and enhances consistency in review of cases by providing a framework for clinical decision making.
Quality Management This program is designed to measure the outcomes of care and services to our members and to apply interventions that improve the level of care and services our member's receive.
Complex Case Management Focuses on the chronically ill members who have a higher utilization of services and are most likely to benefit from intensive management service involvement.
DMCCU The mission of this department is to improve healthcare education, and provide interventions along the continuum of care. They target 5 specific diseases: Diabetes, HIV/AIDS, Pulmonary, Cardiac, and BH.
Patient Centered Medical Home A Team based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes.
Prospective Review Prospective review also known as precertification is the process by which clinical associates determine the medical necessity and appropriateness of a service request from a provider prior to the services being rendered.
Concurrent Review Used mostly for inpatient acute care, rehabilitation, skilled nursing caare, and home care, with home caare being the most common.
Retrospective Review This is the review of services after they have been rendered.
Notification These are authorizations that do not require clinical reviews. Ex. OB Global Notifications
Clinical Review A review that is conducted by NCC or Health Plan case management professional clinical staff.
Criteria Accepted standards used in making decisions or a judgement.These are a set of measureable clinical indicators that reflect a member's need for care. These are objective guidelines for the appropriateness of care.
Guidelines Represent a pathway or plan of care based on best clinical practices. These are evidenced based guidelines that are used along with the reviewer's clinical judgment.
InterQual An example of an industry standard for medical necessity reviews. MCG or Milliman Care Guidelines is another example. They provide a rules-based system for screening proposed medical care based on patient specific, best medical care processes. They are consistent in matching medical services to patient needs, based upon clinical appropriateness.
Created by: mayowd25