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Contact us
To learn more about medical management, check your provider manual (PDF). Or call Provider Relations at 1-855-456-9126 (TTY: 711), 9 AM to 5 PM, Monday through Friday.
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.
All our members have a care management team. The care management team’s goal is to support each member 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.
An integrated care manager will do an initial comprehensive risk assessment for each member. This determines the member’s medical, behavioral health and biopsychosocial status. The care manager then collaborates with the member, member’s family, primary care provider and their other providers to create a quality-focused, cost-effective care plan.
More about care management
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 diabetes and congestive heart failure.
Members get education on disease management, and their care manager will help them create a care plan based on their:
- Understanding of their condition
- Need for equipment and supplies
- Referral for specialty care or other special considerations due to comorbidities
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 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
You can review these policies and guidelines to learn more about medical necessity determinations, coding and coverage decisions.
Aetna clinical policy bulletins
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:
- Identify areas for improvement
- Select the most effective interventions
- Evaluate and measure the success of implemented interventions, refining them as necessary
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 call us at 1-855-456-9126 (TTY: 711).
