Utilization and Case Management definition
Utilization and Case Management means the services provided by Contractor as described in this Attachment A.
Case management means a care management plan developed for a Member whose diagnosis requires timely coordination. All benefits, including travel and lodging, are limited to Covered Services that are Medically Necessary and set forth in the EOC. KFHPWA may review a Member's medical records for the purpose of verifying delivery and coverage of services and items. Based on a prospective, concurrent or retrospective review, KFHPWA may deny coverage if, in its determination, such services are not Medically Necessary. Such determination shall be based on established clinical criteria and may require Preauthorization.
Targeted case management means services that assist a beneficiary to access needed 2 medical, educational, social, prevocational, vocational, rehabilitative, or other community services. The 3 service activities may include, but are not limited to, communication, coordination and referral;
Case management services means planned referral, linkage, monitoring and support, and advocacy provided in partnership with a consumer to assist that consumer with self sufficiency and community tenure and take place in the individual’s home, in the community, or in the facility, in accordance with a service plan developed with and approved by the consumer and qualified staff.
Utilization management section means “you or your authorized representative.” Your representative will also receive all notices and benefit determinations.
Database Management System (“DBMS”) is a computer process used to store, sort, manipulate and update the data required to provide Selective Routing and ALI.