Patient care coordination and case management - Chapter 4, 2022 UnitedHealthcare Administrative Guide

Complex Care Management (CCM) and Transitional Case Management (TCM)

UnitedHealthcare case managers are registered nurses who engage the appropriate internal, external or community-based resources to support the specific Individual Exchange member’s needs. Our complex care nurses are trained to identify and assist individuals with complex medical conditions who need long-term care support, have unmet access or who have care plan, psycho-social, or knowledge needs.

Our transitional case managers will collaborate, evaluate and coordinate post-hospitalization needs for Individual Exchange members who are at risk of re-hospitalization or frequent users of high-cost services.

To refer Individual Exchange members to CCM or TCM, complete the referral form at uhcprovider.com and email it to provider_referral@optum.com. You will receive a status update on the referral within 7 business days. Members must meet program criteria to receive complex care management.

Helping members stay in the network

You play a leading role in helping members stay within their plan’s network. This helps members get the best level of coverage for the highest quality of care. Remember to:

  • Use the online provider directory to find other in-network providers when members require additional care. Go to uhcprovider. com > Find Dr.
  • Submit electronic referrals at uhcprovider.com/referrals.
  • Refer patients to participating lab providers. For more information, go to uhcprovider.com/exchanges > Article: Help Your Patients Save Money.
  • Search for in-network health care providers at myuhc.com/exchange.

Coordinating care for new patients

We understand there can be challenges when a member changes their plan or PCP assignment while undergoing treatment. Here is how you can help:

  • Help the individual become an established patient in your practice.
  • Issue referrals for care that requires immediate attention, especially for those undergoing treatment or who have previously scheduled procedures.
  • Check online to confirm network participation status for the member’s plan.
  • Secure valid referrals and/or prior authorizations before each visit.
  • Partner with UnitedHealthcare regarding member referrals, requests for information or case management opportunities.
  • An out-of-network provider may continue to treat the patient under certain circumstances if pre-approved by UnitedHealthcare.

Coordinating care between medical and behavioral health care

To support coordination of medical and behavioral services, our CCM nurses are trained to identify and assist individuals with complex medical conditions who may also have behavioral health conditions that need follow-up with a behavioral health provider. Additionally, our Live and Work Well website is available to all members as a resource to support individual self-management and to educate and assist members in accessing medical and behavioral services. Learn more at liveandworkwell.com.

Health Risk Assessments (HRA)

Upon enrollment in our Individual Exchange plan, we will ask members to complete an annual health risk assessment (HRA). The purpose of the HRA is to identify and engage members with high-risk needs or conditions to connect them with programs and benefits that will help them navigate care and manage their health. Encourage your patients to complete their HRA. They can do so by phone, email or online.