Services - Care management

Care management & claims

A claimant's experience and quality of care is at the heart of everything we do.

Care management means providing the right care at the right time by the right provider. This requires getting involved early on in the claims process to find high-quality, medically correct services for claimants to ensure they are getting the care they need.

Our care management team achieves this by advocating for our claimants—interacting with physicians and other health care practitioners, providers, insurance carriers, billing offices, and claims processors—and making the quality of care they receive our highest priority.

We also recognize that care needs can and do change over time and regularly verify that the appropriate care is being performed to best meet claimants' needs, help reduce unnecessary costs, and protect against the possibility of fraud.

Care coordination

Acting as individual care managers for long term care claimants and their families, our care coordinators are registered nurses (RNs) who offer an unbiased resource for families to consult with at the often difficult time of finding the right care for a loved one. Our team of compassionate, care-centered experts provide the following services:

Comprehensive claims assessment and benefit eligibility determination
Once an enrollee initiates a claim, we gather the information and documentation necessary and arrange for an in-person assessment to decide if they are eligible to begin receiving benefits.
Development of personalized plans of care
We develop and monitor plans of care for benefit eligible enrollees, searching for and recommending providers, and coordinating a team of health professionals and support services to address care needs.
Access to a discount provider network
Using a database of more than 250,000 providers, we identify and provide claimants with options for local caregivers and sites of care on request. We typically negotiate a discounted rate for the majority of our claimants, with provider discounts ranging up to 25%.
Ongoing claims monitoring
To ensure that a claimant's needs are being met and their circumstances and priorities have not changed, we provide ongoing monitoring of claims.

Claims processing

Fast and accurate claims processing, for claimants, powers of attorney, family members, and providers ensures continuity of care for enrollees when it's time to use their benefits. At the same time, we recognize the importance of establishing controls that prevent misuse in order to protect the program, carrier, and claims experience as a whole.

We're committed to maintaining this balance between monitoring the integrity of our enrollees' claims while providing claims processing services that meet the highest standards of quality. Our services include:

Proactive enrollee communications and workflow to guide and manage claimants' expectations throughout the claims process
Ongoing needs assessment, care advisory, and fraud detection
Informal and home health care management and controls
Claims payment and explanation of benefits (EOB) processing
Provider reimbursement and appeals
Online access to claims history, authorization forms, assignment of benefits, and invoices
Custom claims experience tracking and reporting
Fraud risk management, controls, and prevention
Defined service metrics and turnaround times for benefit eligibility decisions and claims payments that ensure prompt and accurate payments for claimants