Medical management

Case management
This is a collaborative process whereby a case manager from your designated medical management vendor works with you to assess, plan, implement, coordinate, monitor and evaluate the services you may need. Often, case management is used with complex treatments for severe health conditions. The caseworker uses available resources to achieve cost-effective health outcomes for both the member and the medical plans.

Disease management
The purpose of disease management programs is to reach out to you and your dependents who want help managing their health conditions or information about complex or chronic health conditions. The programs are typically designed to improve self-management skills and help make lifestyle changes that promote healthy living. The following disease management programs are available to all members, regardless of their selected networks:

• Asthma.
• Chronic obstructive pulmonary disease.
• Congestive heart failure.
• Coronary artery disease.
• Diabetes.
• Pregnancy-maternity.
   

If you are eligible or become eligible for one of the programs above, a disease manager from your designated medical management vendor will assess your needs and work with your physicians to develop a personalized plan. Your personalized plan will establish goals and steps to help you positively change your specific lifestyle habits and improve your health. Your assigned disease manager may provide the following services:

• Assist with understanding your doctor’s treatment plan.
• Help you to maintain your necessary medical tests and annual exams.
• Offer tips on how to manage stress and help control the symptoms of stress.
• Provide tips on how to keep your diet and exercise program on track.
• Review and discuss medications, how they work and how to use them.

Participation is optional, private and tailored to your specific needs. Generally, a disease manager will work with you as quickly or as slowly as you like allowing you to complete the program at your own pace. Over the course of the program, participants learn to incorporate healthy habits and improve their overall health.
 

Medical management services 
When you choose medical coverage, you get more than basic health care coverage. You get personalized medical management programs at no additional cost. Each medical network provides medical management services as follows:

• American Health Holding serves Blue Cross Blue Shield of Arizona network only.
• UnitedHealthcare serves only UnitedHealthcare members.

Professional, experienced staff work on your behalf to make sure you are getting the best care possible and that you are properly educated on all aspects of your treatment.

Nurse Line
A dedicated team of physicians, nurses and dietitians are available 24/7 for member consultations. Individuals needing medical advice or who have treatment questions can call the toll-free nurse line:

• American Health Holding 866-244-8977.
• UnitedHealthcare 800-401-7396.

Utilization management
AHH  and UnitedHealthcare provide prior authorization and utilization review when members require non-primary care services. Prior to any elective hospitalization and/or certain outpatient procedures, you or your doctor must contact your designated medical management vendor for authorization. Please refer to your plan document for the specific list of services that require prior authorization. Each vendor has a dedicated line to accept calls and inquiries:

• American Health Holding 866-244-8977.
• UnitedHealthcare 800-896-1067.