Administración médica

Please call Member Services at 1-855-232-3596 (TTY: 711) to reach our Care Management Department.

Our care management team supports members based on their personal health risks and unmet needs. A care manager is assigned to each member. They’re part of the medical management team. And their job is to make sure members get all the care and services they need.

First, members are assessed by our licensed:

• Nurses
• Social workers
• Counselors
• Nonclinical professionals

Then, we use a biopsychosocial model to identify what care members need. Finally, the care manager will do a health risk assessment. This determines the member’s medical, behavioral health and biopsychosocial status.

Do your patients need care management?

We can help your patients with certain conditions enhance their self-management skills. This includes conditions like:

• Enfermedad pulmonar obstructiva crónica (EPOC)
• Insuficiencia cardiaca congestiva
• Enfermedades de las arterias coronarias
• Diabetes
• Other conditions

Care management programs may also include topics like:

• Pregnancy outreach and high-risk obstetrics (OB)
• Necesidades especiales de atención médica.
• Behavioral health and substance abuse

Care managers educate members about their condition and how to prevent worsening of their illness or any complications. El objetivo es mantener, promover o mejorar su estado de salud.

To create a quality-focused, cost-effective care plan, care managers collaborate with:

• The member
• Member’s family
• Primary care provider
• Psychiatrist
• Substance abuse counselor
• Other health care team members

To identify members that are the right fit for care management, we may use referrals from:

• Our health info or special needs lines
• Miembros
• Caregivers
• Proveedores
• Practitioners

Integrated care management means your patient only has one care manager, even if they also take part in:

• Administración de salud
• Condition Management

The disease management program helps with regular communications, targeted outreach and focused education. We help members with specific conditions, like:

• Asma
• COPD
• Insuficiencia cardiaca (IC)
• Diabetes
• Hipertensión

After we identify members as having one of these conditions, we automatically enroll them in disease management. So they don’t have to actively enroll. We’ll let you know they’re taking part and work with you to reinforce their treatment plan.

Nuestros programas de manejo de enfermedades ayudan a nuestros miembros a llevar una vida saludable.They learn about their health conditions and how to stay well by working with you. We want to educate and support members, as well as prevent their condition from getting worse. Giving members the tools they need to better manage their health can reduce:

• Hospitalization
• High use of health care resources 

Dedicated care management is here for members who are elderly or disabled. This includes members eligible for managed long-term services and supports (MLTSS). These members have special service needs and risks, such as: 

• The need for more services to improve and maintain quality of life
• Mayor riesgo de institucionalización
• Mayor riesgo de caídas, lesiones (incluidas las fracturas) y eventos adversos
• Mayor riesgo de deterioro cognitivo
• Mayor prevalencia de compra de medicamentos en varias farmacias e interacciones entre medicamentos
• Riesgo de abuso, negligencia y explotación
• Mayor vulnerabilidad a la gripe y enfermedad neumocócica
• Baja tasa de reconocimiento y tratamiento de la depresión
• Necesidad de control del cáncer

Our programs enhance members’ quality of life and ensure optimal health outcomes. These programs include:

• Evidence-based guidelines
• Focused education of members, caregivers and providers
• Review of data that tells us how members are doing

Our goals include ensuring that members get appropriate testing and care for their special needs. We want to help members:

• Reduce avoidable complications of chronic illness, such as diabetes, HF, COPD, hypertension and seizure disorders
• Respaldar el diagnóstico temprano de cánceres de mama, cuello de útero, colon y próstata
• Reducir las lesiones, úlceras por presión y neumonía por aspiración
• Reducir las hospitalizaciones que pueden evitarse, incluidas aquellas que pueden evitarse con una vacuna para la gripe y enfermedad neumocócica
• Respaldar el reconocimiento temprano de la depresión y el deterioro cognitivo
• Evitar o reducir las lesiones
• Mantener la calidad de vida e independencia durante el mayor tiempo posible
• Decrease or prevent long-term institutionalization
• Prevenir e identificar el abuso, la negligencia y la explotación
• Mejorar la calidad de atención
• Help caregivers with support and resources

National recommendations and educational materials are available through the National Institute of Health’s National Institute on Aging.

In addition to news items, you can find publications for physicians and other providers. You can also find multiple health topic booklets relevant to our members who are elderly or disabled: 

• Evaluación de dificultades cognitivas en pacientes mayores: una guía rápida para médicos de atención primaria
• End of Life: Helping with Comfort and Care (PDF)
• Tips for talking with your older patient (PDF)

We hope you find these resources helpful and we look forward to continued collaboration with you to enhance the well-being of these members.

A fall can have a significant impact on members. They can have a fall at home, in the workplace, in an acute care setting or in a long-term care facility. Falls are the leading cause of fatal injury and the most common cause of nonfatal trauma-related hospital admissions among older adults. Members aged 85 and older are up to 15 times more likely to break a hip from a fall than those aged 60 to 65 years.

Los adultos mayores son más vulnerables a las caídas que cualquier otro grupo de edad. But all members can benefit from education about precautions to make homes, hospitals and workplaces safe and free from falls.

Use of certain prescription medications and polypharmacy may make patients unsteady, possibly leading to falls. Try reviewing medications with your patients. Then, suggest these precautions to prevent falls:

• Wear sturdy shoes that have non‑slip soles.
• Always use a handrail when climbing up or down stairs.
• Keep doorways and floors free of obstacles such as throw rugs and furniture.

State law P.L.2019, c.88 mandates the completion of a PRA form for pregnant women receiving state-supported Medicaid health coverage.

La ley comenzó en la legislatura estatal como el proyecto de ley del senado 3406, un paquete de proyectos de ley diseñados para mejorar la salud de las mujeres embarazadas y los recién nacidos. The goal is to decrease rates of maternal and infant mortality in New Jersey. The PRA form is now required documentation for all uninsured, Medicaid presumptively eligible, and Medicaid-eligible prenatal patients. This law impacts obstetric (OB) providers, nurse midwives and other licensed health care providers.

¿Qué deben hacer los proveedores de servicios obstétricos?

OB providers need to submit the required PRA form for reimbursement of OB services. If we don’t receive the forms, you may not receive payment.

If you’re a prenatal care provider, you’ll want to register with Family Health Initiatives (FHI) to access the PRA/SPECT. You can register:

• Online at praspect.org
• By phone at 1-856-665-6000
• By email at PRA@FHIworks.org

Complete and submit the:

• Initial visit PRA form during the first prenatal visit
• Follow-up visit PRA form when there is a change in insurance or you identify a maternal risk factor
• Third trimester visit PRA form at 30 to 36 weeks gestation

Just log in to praspect.org to submit your forms. 

All Network hospitals agrees to comply with the Contractors no payment policy and quality monitoring program consistent with the Centers for Medicare and Medicaid Services (CMS) that addresses Hospital Acquired Conditions and Provider-Preventable Conditions according to federal regulations at CFR 434,438 and 447. The ICD-10 Version 33 Hospital Acquired Condition (HAC) list may be accessed through CMS’s website. The Contractor’s specific policies that have been prior approved by DMAHS are included in the Contractor’s Provider Manual.

Hysterectomy is a covered service if it is indicated for medical treatment other than sterilization. Any claims (hospital, operating physician, anesthesiologist, clinic, etc.) involving hysterectomy procedures must have a properly completed Hysterectomy Receipt of Information form (FD-189) attached when submitted for payment. Without the federally required form, the hysterectomy claim will only be paid if the provider certifies that the procedure was done due to a life-threatening emergency (and a description of the emergency) or that the woman was already sterile and the cause of the sterility is stated (See Chapter 23: Forms (PDF)). These claims must be sent by paper and not electronically.

• Hysterectomies for reasons other than solely or primarily for sterilization would require only the hysterectomy consent form, not both the hysterectomy consent form and the sterilization consent form; and
• Hysterectomies solely for sterilization would require only the sterilization consent form.

Sterilization

Both male and female sterilization procedures require completion of a Consent for Sterilization form (7473 M ED) at least 30 days prior to the procedure. The member must be at least 21 years of age and may not be mentally incompetent. A copy of the signed consent must be attached when the claim is submitted for payment (See Chapter 23: Forms (PDF)). These claims must be sent by paper and not electronically.