Health and Welfare Summary Plan Description

• Health and Welfare SPD / Article VIII / Self-Funded PPO Option >>

8.7 Early Medical Assessment and Case Management.

The Plan has contracted with Blue Shield to provide the following Clinical Management Services which are not designed to interfere with the decisions between you and your medical provider.

1. Preadmission Certification. All medical providers are requested to contact Blue Shield, prior to any non-emergency hospitalizations and out-patient procedures (including acute care admissions, and admission to any skilled nursing or long-term acute care facility) at (800) 541-6652 to verify that services are Medically Necessary and that planned treatment is at the appropriate level of care. This preadmission process also promotes early assessment of high-risk patients that would benefit from disease and high-risk case management administered by Blue Shield.
   
   
2. High-Risk Case Management. This program offers you information and support through a local care manager who is a registered nurse. Your care manager acts as an advocate for you and your family by helping you:
   • Identify treatment options available to you that may assist you in making important healthcare decisions
   • Coordinate your care with your healthcare providers
   • Research additional resources, such as support groups and financial assistance
     1. Here's how it works: A care manager from your area will visit you to understand your needs and to discuss ways he or she can help you. A team of specially trained nurses and doctors will review your treatment options and share the options with you. You can be certain that your medical history and information will be kept confidential. With your permission, the care manager will contact your doctor to offer assistance. Your local care manager will be your primary program contact. However, you and your doctor will always make the decisions about your treatment options. By working closely with your doctor and using the resources available in your community, this program can help you through a difficult time.
3. Disease Management. This program is designed to help members manage their chronic conditions and improve their quality of life for asthma, diabetes, heart disease, coronary artery disease, and chronic obstructive pulmonary disease. This "whole person" approach includes monitoring from an entire team including a pharmacist, nutritionist/dietician and mental health counselor. Enrolled members receive interactive online support, as well as educational mailings and are invited to call as needed. Those at higher risk are contacted telephonically by a registered nurse and certain of those members may be provided with biometric monitoring. Participation in both the high risk case management and disease management programs will not affect your benefits. You decide whether to participate in these voluntary programs. There are no extra charges for this service, and you can leave the program at any time, for any reason.
   
   
4. Mental Health. The clinical management of Mental Health services are managed through Magellan Health Services. Magellan performs medical management services including preauthorization, concurrent review, discharge planning, and aftercare monitoring. The Plan's mental health program through Magellan provides medical care management services for members by specialized clinicians who have access to readily available experts and clinical supports on a 24-hour/7 day a week basis. To access a care manager, call (877) 263-9952.
   
   
5. Substance Abuse. Beat It! Employee Assistance Programs provide Participants and Dependents confidential assistance with substance or alcohol issues. To access the national 24-hour/7 day a week client hotline please call (800) 828-3939. Except in the case of an emergency, pre-authorization by Beat It! is required for full coverage of in-patient substance abuse treatment. See Section 8.9 (32) for Covered Charges.
   
   
6. NurseHelp 24/7. Registered nurses are available around-the-clock to provide no-cost health advice and education to Participants. These services, available at no cost to the Participant, may be accessed either online or by logging onto blueshieldca.com or call NurseHelp 24/7 at (877) 304-0504.
7. Teledoc. California licensed board-certified doctors are available by phone or video 24 hours per day, 7 days per week for consultation on many non-emergency illnesses, including but not limited to allergies, bronchitis, cold and flu symptoms, nausea, rash, upset stomach, sinus infection, and sore throat. These services may be accessed by visiting blueshieldca.com/Teladoc, by downloading the app at teladoc.com/mobile, or by calling (800) 835-2362.