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Acclaim has developed a
comprehensive utilization management program which requires collaboration with
health care providers and enrollees to achieve its overall purpose:
To ensure its members of timely access to high quality, cost effective
health care in the most appropriate setting.
Plan Components
Using pre-established criteria, Acclaim's Utilization Management Program
systematically addresses the delivery of health care services provided to its
members by performing the following activities:
Ambulatory Care Review - These
services are performed when patients require health care services in
which hospitalization is not needed.
Example - diagnostic testing
Preadmission/admission review -
All inpatient admissions require either Pre-Admission or Admission
Review. Pre-Admission Review is performed for elective and some
urgent admissions. The enrollee is ultimately responsible for
notifying Acclaim of any inpatient admission; however, enrollees, the
enrollees' representatives, physician or hospital representatives may
assist with the notification process. Medical information
necessary to authorize the admission must be provided by the admitting
physician, physician's representative or hospital representative.
Concurrent Review - The
purpose of this review is to monitor and evaluate the patient's
conditions and medical care based on information provided by the
attending physician or hospital representative and to determine the
medical necessity for continued inpatient services.
Discharge Planning - These
services are an integral part of any utilization review process in
which opportunities are identified and measures taken to expedite the
transition from the hospital to the outpatient setting. Acclaim
will perform discharge planning during the concurrent review process.
Case Management - These
services include but are not limited to: catastrophic illnesses,
length of stays greater than seven to 10 days, specific diagnoses,
recurrent admissions, and the need for post-hospital skilled services
and/or medical equipment.
Retrospective Review - This
review is available for urgent or emergency inpatient/outpatient
episodes of care occurring after normal business hours or on weekends
or holidays. Acclaim must be notified by the end of the first
business day following the episode of care to initiate the
retrospective review.
Readmission Review - The
purpose pf this process is to identify potential quality, risk,
management and/or utilization issues. Findings are subject to
review by the Utilization Review/Quality Improvement committee and may
be trended for pattern analysis.
Second Surgical Opinion -
These services will be provided in accordance with the contractual
agreement between an employer and Acclaim.
On-Site Review - This review
shall be limited to those issues which cannot efficiently be addressed
in the usual review processes. Examples include but are not
limited to: large case management and unresolved claims issues
in which the medical record must be reviewed prior to payment of a
claim.
Non-Acute Care Review -
Acclaim shall conduct non-acute care review activities in accordance
with contractual agreements with employers. These services must
be pre-approved by the Case Manager prior to delivery of
services. The following non-acute services are subject to
review:
Skilled Nursing or
Rehabilitation Services
Home Health Services
Durable Medical Equipment, Prosthetic and Orthopedic
Appliance Use
Private Duty Nursing Services |
Quality Improvement Program
As a comprehensive program, the
Quality Improvement Program encompasses two major categories; quality of
service and quality of care. While quality of service reflects
Acclaim's business processes and its commitment to service, quality of care
reflects both the provision and outcomes of care.
| Member Satisfaction - a quarterly
survey in which members are given the opportunity to rate Acclaim's
performance including accessibility;
Complaint/Grievance Policies and
Procedures - a data collection tool that provides information for
trending quality of service concerns including Acclaim's timeliness of
response;
Staff Performance - a continuous
monitoring process of staff's compliance to policies and procedures. |
| Readmission Review - a process to
identify premature discharges, complications related to previous
medical intervention or lack of intervention and/or alternative
treatments;
Mortality/Morbidity Rates - a monthly
trending of all deaths or complications;
Provider Resource Utilization - a
monthly trending and analysis of all participating providers' average
lengths of stay. |
Review Criteria -
Under its licensing agreement with InterQual, Acclaim's review staff shall use
the appropriate criteria set as a screening tool to make an initial
determination as to the indications for a proposed or performed medical
service.
Appeals Process - The
purpose of Acclaim's Appeals Process is to provide the patient, enrollee,
attending physician and/or other provider an avenue to challenge or address
any adverse determinations made by Acclaim staff.
Complaint Policy -
Acclaim commits to address and document any complaint which is reported by a
complainant. The term refers to a member, a member's representative, an
employer or a provider.
Confidentiality Policy -
In accordance with state and federal laws, Acclaim restricts its requests to
information necessary to conduct business. Acknowledging the sensitivity
of the information and the patient's and physician's right to privacy, Acclaim
has adopted a strict confidentiality policy.
Accessibility Policy -
Acclaim enrollees needing to preauthorize an admission or other health-related service
may contact Acclaim's Utilization Review Department at 1-800-315-4147, Monday
through Friday, 8 a.m. to 5 p.m. CST with the following exceptions:
New Year's Day
Memorial Day
Independence Day
Labor Day
Thanksgiving Day
Christmas Day |
To meet member and provider
needs and expectations, voice mail will be activated after normal business
hours, during weekends and holidays.
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