ANSWER
Conifer Health is a certified health solutions company and a national leader in personal health management and healthcare technology. With 30 years in the healthcare industry and on-the-ground experience in 135 markets nationwide, Conifer knows the ins and outs of local health systems, physician groups, employers and unions. Conifer helps members navigate the healthcare system and provide the tools for them to adopt healthy behaviors through collaboration and education. The Utilization Management provisions of the Trust’s Plan are administered by Conifer, our Utilization Management Vendor. The staff at Conifer are Physicians and Registered Nurses who monitor the use of your health care benefits to ensure that you and your family:
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a. Receive the best medical care possible in the most appropriate health care setting;
b. Avoid unnecessary surgery and excess hospital days; and
c. Receive answers to questions you have regarding medical care.
Components of the Utilization Management program include:
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a. Pre-certification of all hospital admissions,
b. Continued Stay Review of all hospitalizations;
c. Pre-certification of all Outpatient surgeries and the following: Residential Treatment Facility for Mental Health and Substance Abuse (considered inpatient); Birthing Centers; Clinical Trial Patient Cost Coverage; Intensive Outpatient Services for Mental Health and Substance Abuse, Durable Medical Equipment over $1,500 per Calendar Year; Home Health Care; Hospice Care; Skilled Nursing Facility, and Surgical treatment of morbid obesity;
d. Case management of potentially catastrophic cases;
e. Disease Management.
Pre-certification, continued stay review, and outpatient pre-notification decisions are based on the medical policy guidelines of the Utilization Management Vendor. Otherwise, all Medical Necessity reviews will be performed by the Claims Administrator utilizing CareFirst BlueCross BlueShield and other applicable medical policies.