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Medical management
The goal of our medical management team is to promote cost-effective care that helps members be as healthy as they can be. This means working with providers to assess conditions, create care plans, coordinate resources and check progress.
Care management
Care management
Our goal is to improve access to quality care and avoid unnecessary medical costs. We try to help with the efficient use of medical resources for members with special health care needs, including complex, chronic and catastrophic cases.
We identify members who might benefit from care management through:
- Utilization management activities
- Health risk assessments
- Screening of administrative data
Our care management team supports members based on their personal health risks and unmet needs. A care manager is assigned to each member. They’re part of the medical management team. And their job is to make sure members get all the care and services they need.
First, members are assessed by our licensed nurses, social workers, counselors or nonclinical professionals. Then, we use a biopsychosocial model to identify what care members need. Finally, the integrated case manager will do a health risk assessment. This determines the member’s medical, behavioral health and biopsychosocial status.
- Pregnancy outreach
- Special health care needs
- Behavioral health and substance use
Members can self-refer for care management. Or you can refer them. Just call:
Medicaid STAR
- 1-800-248-7767 (TTY: 711) (Bexar)
- 1-800-306-8612 (TTY: 711) (Tarrant)
CHIP or CHIP Perinatal
- 1-866-818-0959 (TTY: 711) (Bexar)
- 1-800-245-5380 (TTY: 711) (Tarrant)
Service coordination is for STAR Kids members. It’s a type of care management service. Service coordinators:
- Work with children, their caregivers and providers to get the right care from birth to age 20
- Help maximize a member's health, well-being and independence
- Work with the member’s primary care physician (PCP) to coordinate services
You can refer a member for service coordination. Just call 1-844-STRKIDS
(1-844-787-5437) (TTY: 711).
Risk scores
The state assigns a risk score to health plans based on the number and type of chronic conditions members have. Accurate risk scoring requires these conditions to be documented in claims.
Chronic disease management
Chronic disease management
The chronic disease management program helps with regular communications, targeted outreach and focused education. We help members with specific conditions, like asthma and diabetes.
Members get education, coaching and other services to help them manage their condition. They also receive help from disease management nurses. These nurses perform or facilitate health risk assessments. They can also create an action plan based on the member’s:
- Understanding of their condition
- Need for equipment and supplies
- Referral for specialty care or other special considerations due to comorbidities, including behavioral health and substance abuse
Utilization management (UM)
Utilization management (UM)
The purpose of UM is to manage the use of health care resources to ensure that members get the most medically appropriate and cost-effective health care. The goal? Improving medical and behavioral health outcomes.
The UM team will help providers:
- Complete authorization requests submitted by fax or through the Provider Portal
- Review clinical guidelines and requests for peer-to-peer reviews
- Identify discharge plans for members leaving a hospital or facility
Quality management (QM)
Quality management (QM)
The main goal of this program is to improve the health status of members. Our QM program uses multiple organizational components, committees and performance improvement activities to find opportunities for success. This allows us to:
- Assess current practices in both clinical and nonclinical areas
- Identify areas for improvement
- Select the most effective interventions
- Evaluate and measure the success of implemented interventions, refining them as necessary
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a widely used performance improvement tool. Visit our HEDIS page for more info.
We have a comprehensive ongoing Quality Assessment and Performance Improvement (QAPI) program that:
- Focuses on the quality of clinical care and services to our members
- Helps ensure that members get preventive health care in a timely manner
- Provides care management services to people with special health care needs
- Adheres to state and federal requirements
- Is overseen by the Governing Board of Directors and Quality Oversight Committees
Performance improvement and measurement are fundamental to the QAPI program. We can’t improve what we don’t measure. So we analyze encounter data to identify gaps in care and recommend opportunities for improvement. Your involvement, feedback and recommendations for improving the delivery of care and services are welcome. Just contact us.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).