Programs to Help You Maximize Your Health Insurance Plan
Cox HealthPlans' Medical Management Programs offer a variety of ways to help accomplish two crucial goals: partnering with our members to help them live the healthiest quality of life possible, and controlling health care dollars spent.
As part of your health care benefit the Cox HealthPlans Medical Management team coordinates these programs to support our members' needs. This team consists of Registered Nurses, Certified Case Managers, Medical Resource Specialists, and a Board Certified Physician.
Medical Management programs are continuously being developed and deployed to meet the needs of our members in an ever-changing health care industry. We believe in taking a proactive management approach where Cox HealthPlans' Medical Management team identifies health care management needs and contacts members to ensure the best outcomes possible. Our team also assists with self-referred cases. We can be contacted by phone or in person Monday through Friday from 8 a.m. – 5 p.m
Key Program Elements
- Transition Care
- Complex Care
- Advanced Illness Care
- Specialty Medication and Disease Management Program (SMMP)
- Pharmacy Management Initiative
- Emergency Room/Urgent Care Utilization
- Out-of-Network Utilization
- High Dollar Claim Review
Medical management is integrated in your health care benefit, with many services exclusive to Cox HealthPlan members. Cox HealthPlans, in a unique partnership with CoxHealth, can provide members with the knowledge and information needed to make informed care decisions that will maximize plan benefits and ultimately result in a higher level of overall quality outcomes. This partnership allows medical and pharmacy claims, health records and enrollment data to be combined with the health system's clinical resources, creating a comprehensive approach to identification, outreach and targeted care for our members. Unlike other standard medical management programs that only use claims data, our program integrates and coordinates all health system resources for our members. All Cox HealthPlans members are eligible for medical management.
Through data analytics and algorithms, members are uniquely identified and the outreach process begins. Members will be contacted and engaged based on their specific needs. The CoxHealth care team performing the services consists of physicians, registered nurses, pharmacists, community health workers, case managers, social workers and dieticians. The health system care team will collaborate with Cox HealthPlans' Medical Management Department to ensure complete care and service is provided.
Through Population Health Management, Pharmacy Management, and Healthcare Utilization Management techniques, our team identifies areas we can assist members, their families and providers. This ensures that our members receive timely, appropriate services to achieve the following goals:
Goals of Member Outreach:
Promoting high-quality, cost-effective medical care
Empowering members to take control of health care needs (self-management)
Fostering higher-quality outcomes and better disease control
Connecting members to In-Network providers
Introducing members to a multitude of educational opportunities and resources