Here are just some of the quality care assurance initiatives we have in place.
Medical Management Plan
Our Medical Management Program is designed to monitor, evaluate and positively influence the provision of cost-effective medical care throughout our affiliated care providers. This self-funded program relies on feedback from members and providers to make sure we’re hitting the mark.
Behavioral Health Program
Our Behavioral Health Program is designed to assess, monitor, and improve our behavioral healthcare services. This includes outpatient services (individual counseling, substance abuse counseling, family counseling, and urgent care clinic access); community services (rapid response intermediate care, structured adult dependency programs, and partial hospitalization programs); hospital care (psychiatric care in hospitals, as well as acute hospitalization for substance abuse); and extensive behavioral care services (services delivered by practitioners and providers within HealthCare Partners Nevada, Harmony Healthcare, and contracted providers networks.)
Peer-to-Peer Discussions for Medical Necessity Denials
We ensure a physician reviewer is available to discuss medical necessity denials and offer second opinions. A specialty-appropriate provider will be assigned by HealthCare Partners Nevada to talk to the original practitioner about a Utilization Management (UM) denial decision. The reviewer may be a physician, pharmacist, chiropractor, dentist or another practitioner type. This opportunity will be afforded to you and documented by HealthCare Partners Nevada, either before or after the issuance of the denial.
Behavioral Health Program Description and Work Plan
Our Medical Services Organization (MSO) implements an annual behavioral health program description and quality improvement/utilization management work plan. The program description provides a detailed outline of our program and the work plan details the specific activities, objectives, and performance standards. UM decision-making is based on appropriateness of care and services and the existence of coverage. The program description, annual work plan and evaluation, and Utilization Management decision making criteria are available at your request. If you are interested in receiving a copy, please contact our Quality Management department at 702-318-2450.