Medical Management and Authorization
What is Medical Management?
The Medical Management (MM) program consists of ongoing authorization and coordination of each member's care.
- Purpose: Serve as the member's advocate to facilitate and implement equal access to medical care for each member.
- Span: Inclusive of both the inpatient and outpatient settings of medical health care.
- Core Function: Evaluate the appropriate allocation of resources based on medical necessity.
- Scope: Ensure that each medical management function is structured to ensure consistent and prompt decision-making.
You may call Medical Management at (888) 327-0671 or (810) 733-9707 if you would like to speak with the Chief Medical Officer about a utilization denial or any utilization issue.
Criteria Availability
McLaren Health Plan's Utilization Management Program is structured to deliver fair, impartial and consistent decisions regarding health services. There are industry standard written criteria that are used when determining if health services are medically necessity. The criteria used in the decision making are available to you upon request by calling the Medical Management Department at (888) 327-0671 or (810) 733-9722.
Behavioral Health services are not subject to any medical necessity review at this time.
UM Denials
If a provider requests services for a member that are not authorized (denied), written notification will be provided and will include specific reasons for the denial as well as appeal rights. In addition, McLaren Health Plan’s Chief Medical Officer or other appropriate practitioners will be available by phone to discuss any utilization issue and the criteria utilized in the decision-making. Peer to peer requests may be made within the established member appeal rights time frame (Medicaid 60 days, Community and Health Advantage 180 days). Please call the Medical Management department at (810) 733-9707 to make an appointment to speak to the reviewer.
Incentive Programs
Utilization decision-making is based only on appropriateness of care and service and existence of coverage. We do not specifically reward practitioners or other individuals for issuing denials of coverage, service or care. Nor are there financial incentives for utilization decision makers to encourage decisions that result in underutilization.
Clinical Practice Guidelines
McLaren Health Plan uses the MQIC Clinical Practice Guidelines, which are standards of care for doctors to follow, to aide doctors and members to make decisions about appropriate health care.
McLaren Health Plan's Chief Medical Officer (CMO) and the Quality, Safety, and Satisfaction Improvement Committee (QSSIC) has final approval and responsibility.
McLaren Health Plan's disease management programs are based on the MQIC Clinical Practice Guidelines. If you have any questions about McLaren Health Plan's Clinical Practice Guidelines, or if you would like a printed copy of any guideline, please call Customer Service at (888) 327‑0671.
Last Updated 01/09/2018
Please Note: There may be links on the McLaren Advantage website that take you to non-McLaren Advantage information. By clicking these links you will be leaving the McLaren Advantage web pages.
Neonatal Care Management Partnership
McLaren Health Plan has entered into a partnership with ProgenyHealth, an organization that specializes in neonatal care management services. This partnership provides additional support from a team who understands the complexity and stress of managing infants in the NICU, sharing best practices and working with our members to achieve the best possible outcomes.
Beginning Dec. 1, members of McLaren Health Plan's Community, Health Advantage and Medicaid plans will have access to ProgenyHealth’s pediatricians, neonatologists and neonatal nurse care managers to promote healthy premature and medically complex newborns. Members will receive a dedicated case manager who will help support and educate as well as having an on-call staff member available 24/7. Member enrollment is based on NICU admission data and is done automatically.
For more information visit www.progenyhealth.com