Medical management model
This approach to care management was specifically designed to meet the needs of Medicaid recipients.
Utilization management
Our utilization management (UM) program uses an integrated medical management model based on the physical, behavioral, and social needs of members. The UM program, in collaboration with other departments such as Care Management and Condition Care, facilitates the delivery of the most appropriate medically necessary care to members in the most cost-effective, least-restrictive setting.
Care management model
Our member-centric care management model integrates behavioral, physical, and social factors into each individual member’s plan of care. Our model features the early identification of needs, continuous assessment of health and a member home approach that promotes collaboration among members, family, service coordinators, providers, and community resources.
By collecting individualized data from intake information upon enrollment, historical claims data and ongoing concurrent review, we develop a predictive model that stratifies members into levels of care that determine the level of intervention. Stratification is refined and targeted to those conditions and episodes of care that are most impactful. The care plans developed based on this information are specific to a member's needs. The members’ provider(s) are also engaged in the development and execution of the plan, so the care is integrated across physical, behavioral, and social spectrums.
Learn more
To learn more about our utilization management program or our care management model, please refer to your provider manual or contact Provider Services.
Interested in becoming a provider in the Wellpoint network?
We look forward to working with you to provide quality service for our members.