Precertification

Utilization Review

Case Management

Assisting patients and helping control plan costs

HCPC provides a comprehensive program to identify serious illnesses or injuries and ensure that services being rendered are medically necessary and are rendered in the appropriate setting

Pre-Certification/Utilization Review

• Pre-certification for elective, same-day surgery, and maternity admissions Review of diagnosis and proposed treatment facility
• Initiate contact with the physician or the facility as needed
• Maintain contact with the patient, the physician, and the in-hospital case manager
• Provide continual evaluation of patient care needs.

Case Management

Case management interfaces with utilization review to coordinate services. The case manager plans, coordinates monitors, evaluates and implements services to meet the patient’s medical needs. The case manager:

• Assures that care being rendered is appropriate

• Determines if care is being provided in the appropriate setting

• Maximizes benefits through pre-arranged agreements with home health care agencies, medical equipment vendors, and other health care providers

• Negotiates point of service contracts as necessary