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Case Management

GLO-PRV-Case Management

Our Behavioral Health Case Managers are experienced health care professionals who are available to engage telephonically and guide members through the complexities of the health care system to support their mental health and substance use disorder needs. Behavioral Health Case Management is available for Commercial, Medicare and Safety Net Lines of Business.

Case Management Program Contact Information

  • For Access to Behavioral Health Case Management for Commercial & Medicare Lines of Business; call toll free 1-800-277-2198 Monday through Friday 8 a.m. to 5 p.m. EST. If you call after hours, leave a voicemail and your call will be returned the next business day.
  • For Access to Behavioral Health Case Management for Safety Net Lines of Business (Medicaid, Health & Recovery Plan (HARP), Essential Plan, and Child Health Plus Lines of Business; call toll free 1-844-694-6411.

Safety Net Case Management

The Safety Net Care Team consists of several case management departments which are staffed by both clinical and non-clinical nurses, social workers, and mental health professionals. The licensed staff within the Behavioral Health (BH) Department is largely made up of licensed behavioral health clinicians who came to the health plan with a variety of direct experience in the field. 

The BH team addresses primary mental health and substance use related diagnoses, and through an integrated approach the team works closely with the physical health department to help telephonically manage members with co-morbid conditions. 

The Case Management teams’ efforts are aimed towards increasing member’s overall health and quality of life, reducing avoidable inpatient and emergency department visits, and providing members with support towards their recovery goals.
The most current consent forms can always be located on the ExcellusUnivera website.

Special Populations

The goal of managing Special Populations is to provide integrated case management of members identified as belonging to a high risk group.  
Special efforts are made to identify the members to ensure:

  • Timely access to care
  • Continuity of member's care,
  • Coordination and integration of physical and behavioral health care
  • Proactive engagement into case management.

Examples of high risk groups that are in need of high touch case management are members who are homeless, members who were recently incarcerated, transitional aged youth and individuals with intellectual or developmental disabilities. Providing a focused, integrated case management model assists our members in transitions of care and obtaining resources to assist them in overcoming barriers.

Health and Recovery Plan (HARP)

A HARP is a managed care product that manages physical health, mental health, and substance use services in an integrated way. HARP's manage an enhanced benefit package of Home and Community Based Services and provide enhanced care management for the members to help coordinate their needs holistically.

Who is eligible for HARP's?
This product is for members 21 years old or older, insured only by Medicaid members who are also eligible for Medicaid Managed Care. The state identifies members with significant behavioral health needs to become eligible for this product.

Health Home

Health Home is a Care Management service model, not a physical place, where all providers are working together to address the needs of the member to ensure the member receives the services and care he/she needs to remain healthy.  Once enrolled in a Health Home, the member will work with a Care Manager to assess needs and to develop a care plan to address those needs.  Some services may include connecting to health care providers, assistance obtaining prescribed medication, help with housing, etc.

Who is eligible for Health Home? Member must be enrolled in Medicaid and must have:
Two or more qualifying conditions (Substance use disorder, asthma, diabetes, etc)
OR
One single qualifying chronic condition of HIV/AIDS or Serious Mental Illness (SMI)

Transitions of Care

The EHP Case Management team assists in coordinating and monitoring transitions of care for members who have been identified for an acute behavioral health need such as inpatient or emergency department visits. Members that are transitioning from one level of care to another are especially vulnerable and can often benefit from additional support to navigate the health care system.

The team works to engage with the member and providers prior to discharge to develop a relationship with the member and contribute to discharge planning when appropriate. The team then follows the individual’s case post-discharge to help facilitate engagement with outpatient treatment within 7 days, as engagement within this time frame has shown to reduce re-admission rates.

The Case Managers at EHP strive to improve every member transition of care through open communication, collaboration, and education. 

Enhanced Bright Beginnings – SUD & CM

The primary objective is to identify and engage pregnant women with substance use disorder (SUD), past or present, into care management. Ideally, decreasing the likelihood of delivering babies with Neonatal Abstinence Syndrome (NAS). 

This enhanced program is unique as the management is from a collaborative approach. All women engaged have both a medical care manager specializing in obstetrics and a behavioral health care manager with SUD expertise. These members preferably stay engaged with the behavioral health care manager for 12 months postpartum.

The ongoing engagement of these women is attributed to the face-to-face aspect (diaper incentive), as well as the clinical knowledge of the case managers. The model also allows the case managers to meet the members where they are at in their recovery process.

Peer Services

Through our work in Medicaid Managed Care, we are pleased our provider partners are integrating or collaborating with Certified Peer Specialists (CPS) or Certified Peer Recovery Advocates (CPRA). We believe that to help create a highly engaging, responsive, and recovery orientated system, these unique types of service providers need to play an active role. CPS & CPRAs are individuals who have personal lived experience with behavioral health issues and, most importantly, have experience with the process of change known as recovery. In short CPS & CRPAs are the evidence that recovery is more than just a concept; it’s a reality. CPS & CRPAs possess the skill set needed, confirmed by their certification, to use this lived experience as an expedient way of forming meaningful connections, building trust, & promoting hope. From this paradigm of affiliation, they can assist members along on their journey of recovery through activities including:

  • Addressing social determinants of health, accessing entitlements, & navigating systems
  • Supporting person-centered planning, shared decision making, and the member taking an active role in their health
  • Helping connect the member to support groups & social opportunities
  • Assisting with recovery & crisis planning, symptom management, and engagement in wellness activities

In this time of change within the healthcare system, providers & stakeholders are looking for innovative care models to increase value offerings. This has drawn more attention to Peer Services, as Peers have shown the ability to engage members that may be less responsive to traditional approaches. The peer is then positioned to serve as an ambassador for other healthcare professionals, leading to a recovery orientated team approach in promoting community living capabilities and service utilization efficiencies. Visit Mental Health America for more info on the evidence of peer services

Ways a member can access peer services are through the Office of Alcohol & Substance Abuse Services Outpatient Clinics. Peer Services are Medicaid billable within that setting. Another way to access peer services is through the Home Community Based Services (HCBS) benefit package for Blue Option Plus (Health and Recovery Program) members. The benefit package also contains Short Term Crisis Respite services that are often delivered through a peer-run model (Peer Run Respite). To access these services a HCBS assessment & Plan of Care needs to be conducted by Health Home Care Manager or a Recovery Coordination Agency.  The Health Plan will work with these providers to ensure planning and services are aligned with state and federal guidelines. CRPA & CPAs can be found in other programs as well, such as Health Home Plus teams and Assertive Community Treatment teams.

If you would like more info on connecting a member to Peer Services, please call our care management line.

Consents

When a need for member consent extends outside of the contractual partnership between the health plan and the provider, an additional Release of Information can be obtained through the ExcellusUnivera website.

To facilitate smoother communications with the health plan case managers, there are situations where it will benefit the member and provider to complete the consent form and send it to the health plan.

The most current consent forms can always be located on the ExcellusUnivera website.