While strictly adhering to your plan documents, Utilization Management helps decrease costs by monitoring medical necessity, length of stay and appropriateness of care. SHDC’s goal is to keep patients in-network, thus reducing out-of-network costs. The services are customized to meet the needs of any applicable plan documents. The National Committee for Quality Assurance (NCQA) guidelines is met because the services operate twenty-four hours per day, seven days per week, including weekends and holidays. Strategic Health Development Corporation is "URAC" Accredited for Utilization Review.
 

Strategic Health Development Corporation as part of the Utilization Management Program provides the following services:

• On-site nurse coverage 24 hour a day, 7 days per week

• Pre-certification, when required by your plan documents, which; could include inpatient, outpatient, elective procedures, diagnostics, therapies and any other needs

• Network guidance/channeling

• Concurrent Review

• Retrospective Review

• Physician Advisor Review

• Second Opinion Program

• Appeals Process

• Access to PPO networks nationwide and internationally if needed

• Identification of potential Care Management clients by notifying   payers of high dollar cases or disease based identifiers

• If requested, notification to re-insurers of pre-certifications   reaching high dollar levels

• Discharge Planning

• Multilingual Clinical Staff

Strategic Health offers a per employee per month (PE/PM) pricing arrangement. The high cost of "assembling" Utilization Review services is eliminated because the pricing is all-inclusive to meet any needs requested. Private label programs are also available.
 

Strategic Health maintains flexibility to meet the clients' specific needs. Strategic Health is committed to helping you manage your benefit plan and decreasing costs by ensuring adherence to the policy guidelines in the applicable plan documents and insurance policies.
 

The patient, physician, hospital or provider may initiate the certification/authorization process. All requests are reviewed within twenty-four hours of notification, upon receipt of pending medical information, and thereafter as indicated. Determinations are made in accordance with acceptable medical standards and appropriateness of care. Any requested certifications/authorizations that do not meet criteria will be discussed with the Physician Advisor for recommendations. Solely the Physician Advisor makes adverse determinations. All notifications of certifications/authorizations are forwarded to the physician, claims administrator, patient, hospital, other providers, and/or other entities that may be requested via fax, mail or electronic transmission. Strategic Health complies with HIPAA regulations.
 

This program was developed for HMO's and those who already have a Utilization Management Program in place. Since many hospitalizations take place outside the hours of eight to five, Monday through Friday, Strategic Health has developed this program to decrease costs, especially those due to out-of-network admissions. Strategic Health has been providing these services for over thirteen years for numerous companies. The After Hours Program is a seamless, private label product in which your company's functions are taken over after hours: 5pm - 8am, Monday through Friday, weekends and holidays. This service enables compliance to meet NCQA guidelines for twenty-four hour coverage. The nurses follow your guidelines and answer the phone in your company's name. Certifications/authorizations are completed throughout the after hour period and either faxed or transmitted electronically on a daily basis.
 

• Assures medical necessity of services and appropriateness of   admissions and emergency room visits

• Meets NCQA and URAC guidelines by providing 24-hour coverage, including weekends and holidays

• Verifies eligibility and membership

• Assures clients stay in-network

• Attempts to transfer a patient who is admitted to an out-of-network   facility to an in-network facility if the client is stable and can be   treated by an in-network physician

• Makes cost effective coverage available, priced on a pe/pm arrangement

• Provides licensed professional nurses on premises at all times