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Case Management

Meritain Health's Case Management Program actively manages the complex and costly care of the chronically ill or catastrophic patients. The Case Manager collects in-depth information about a patient?s situation and functioning level to identify individual needs in order to develop a comprehensive case management plan. Information from all relevant resources is gathered to determine if the patient is reaching the desired outcomes and goals.

Meritain Health's Case Managers follow all inpatient and outpatient psychiatric/substance abuse cases, inpatient medical rehabilitation, skilled nursing facility, home health care, private duty nursing, and hospice cases. We also offer a comprehensive Baby Steps Program following the member or spouse through her entire pregnancy consulting with the physician to achieve the best outcomes. Our nurses try to steer the patient/discharge planner to utilize in-network providers so the claims will be paid in-network using the PPO discounts. Utilization Management will negotiate pricing for all out-of network Home Health Care, inpatient rehab/SNF, hospice, home infusion, psychiatric/substance abuse cases during the initial authorization process. If we cannot secure a discount at the time services are being rendered for an out-of-network inpatient admission, the Cost Containment Unit will initiate the negotiation process once the claim is received.

We provide the member and their family with information to allow them to participate more fully in treatment decisions. With specialized skills and education, the Case Manager can help identify the most cost effective setting of care while helping to ensure healthy outcomes.