Case management and disease management programs, Oxford - 2021 UnitedHealthcare Administrative Guide

We created a number of programs designed to improve outcomes for our members and to allow us to better manage the use of medical services. You may refer members to these programs, or members may self-refer.

For more information, go to > Providers or Facilities > Tools & Resources > Medical Information > Managing Disease or by calling our Member Service Department.

Case management and disease management programs referrals

You may refer members, or members may self-refer to several Case Management and Disease Management programs. These programs are designed to improve outcomes for members and to help us better manage the use of medical services.

For a complete list of Case Management/Disease Management programs go to > Providers (or Facilities) > Tools & Resources > Managing Disease: Programs for Members.

Healthcare effectiveness data and information set measures

The annual Healthcare Effectiveness Data and Information Set (HEDIS) was developed by the National Committee for Quality Assurance (NCQA). NCQA is an independent group established to provide objective measurements of the performance of managed health care benefit plans, including access to care, use of medical services, effectiveness of care, preventive services, and immunization rates, and each benefit plan’s financial status.

CMS, state regulators (commercial) and prospective members use HEDIS measures to evaluate the value and quality of different health plans.

Each year we collect data from a randomly selected sample of our members’ medical records for HEDIS. HEDIS is mandated by the New York Department of Health, New Jersey Department of Health and Senior Services, Connecticut Department of Health, and CMS. The HEDIS medical record study measures our participating care providers’ adherence to nationally accepted clinical practice guidelines.