Indemnity Provider Manual - Maryland

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Policy Statements

Care Management

MSSOP is aimed at containing costs by reducing unnecessary diagnostic and surgical procedures. It also has the added benefit of providing reassurance to patients having elective surgery by either confirming the need for the surgery or advising them of other forms of treatment. Some employer groups elect Voluntary Second Surgical Opinion (SSOP) while others choose Mandatory Second Surgical Opinion (MSSOP) for certain procedures. If a subscriber's contract requires MSSOP, a penalty is applied if the SSOP is not obtained. A practitioner who is qualified to perform the surgery must perform the SSOP. The program applies to a specific list of diagnostic and surgical procedures when they are performed on an elective, non-emergency basis. The procedures on the MSSOP list vary from account to account. Check BlueLine to verify procedures.

These are inpatient admission review programs designed to contain hospital costs by reviewing admissions for appropriateness of the admission and number of inpatient days. These programs feature preadmission review, admission review, continued stay review, retrospective review, and discharge planning. These programs require that the CareFirst Utilization Management department be notified of admissions (see Important Telephone Numbers).

The Coordinated Home Care and Home Hospice Care programs allow recovering and terminally ill patients to stay at home and receive care in the most comfortable and cost-effective setting. In order to qualify for program benefits, the patient's physician, hospital or home care coordinator must submit a treatment plan to CareFirst. A licensed home health agency or approved hospice facility must render eligible services. Once approved, the home health agency or hospice is responsible for coordinating all services.

ICM is a voluntary program available to those members who have acute illnesses in a variety of specialty areas including AIDS, oncology, neonatology, pediatrics, high-risk obstetrics, head injury, spinal cord injury as well as medicine and surgery. Case management serves to coordinate and support services that are aimed at assisting the member's attainment of short-term health objectives and long-term goals.

Health care providers, patients, family members, employers or anyone familiar with the case may refer candidates for ICM (see Important Telephone Numbers).

OPAP is a pre-treatment program that applies to outpatient physical, speech and occupational therapy. This program requires that CareFirst approve a certification form prior to a given visit (e.g., before the tenth visit) or prior to the first visit depending on the subscriber's contract.

The provider of care must complete a form that includes the patient's diagnosis and expected length of treatment. The care will then be reviewed, and the provider and subscriber will receive written notification of the decision.

Magellan offers a full array of managed mental health, substance abuse, and Employee Assistance Programs (EAP) services, including utilization management, PPO, HMO and point-of-service networks. Magellan offers programs designed with a patient-advocacy focus such as Care Management and Enhanced Utilization Management.

Care Management is Magellan's network-based clinical service program. It combines the best attributes of utilization management with the clinical skills and experience of a care management team that guides referrals and serves as a patient's advocate through the entire episode of care.

Enhanced Utilization Management is a utilization review process that works with each member's provider to ensure medically-necessary treatment in the most appropriate setting.