A Coordination of Health and Wellness Care … Because You Matter

The Utilization Management team works with providers through our members’ healthcare journey. Our Utilization Management team reviews all requests to ensure the care members receive is timely, appropriate, and necessary.

The purpose of the Utilization Management program is to control healthcare costs through management of the use of healthcare resources. By meticulously managing healthcare resources, we ensure that members receive the most medically appropriate and cost-effective healthcare to improve their medical and behavioral health outcomes.

The Utilization Management team makes medical necessity determinations based on established criteria. The criteria used to make determinations is available to providers.

The Utilization Management Department is responsible for monitoring the use of healthcare services before the services are delivered to confirm all services are:

• Provided at an appropriate level of care and place of service. When appropriate, we help members transition to network providers
• Included in the member’s benefit plan, and are appropriate, timely and cost-effective
• Accurately documented to facilitate accurate and timely reimbursement

To learn more, click the images below for more information from the CDC about the utilization of doctors and facilities.

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Utilization of doctors and facilities - Click the image for more info from the CDC.

The Case Management team takes a comprehensive approach to improving your health. We work to provide you with appropriate resources and the information you need to get the most out of your healthcare benefits. Our Case Management process provides an assessment of your current health state and helps you establish goals to manage your health better.

Our Case Management team is made up of nurses and social workers to assist you with your needs. We want to help you get the care, information, and community services you need. The Case Management program promotes quality, cost-effective outcomes through assessment, planning, coordination, education, and referral. Our case managers may contact you if you have recently had a long hospital stay, have a new cancer diagnosis, have a complex medical issue, or if you require specialized care from an out-of-network provider.

The Case Management program is provided at no charge for AultCare and PrimeTime Health Plan members who would like to participate.

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Case management starts with coordinating preventative care and beyond, before issues arise. Click the infographic to learn more.

The Disease Management team focuses on providing members with education on prevention and ensuring members with chronic health issues have all the tools and services necessary to improve their health.

Our Disease Management team offers an integrated and comprehensive approach to manage conditions, reduce complications, improve quality of life, and decrease costs. Our nurses reach out to members with diagnoses such as Diabetes, Congestive Health Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), and mental health concerns. These members will receive targeted materials to introduce available opportunities and AultCare Care Coordination resources.

Nurses will also contact members for preventive care reminders and available educational programs. Common reminders our nurses provide are preventive screenings, adherence follow-up, medication follow-up, and information on how to improve overall outcomes.

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Video - Disease Management - Stroke Awareness

Video - Disease Management - Women's Well Visit

The AultCare Wellness team is a robust, motivated, and knowledgeable team comprised of nurses, dietitians, personal trainers, and tobacco cessation specialists. The focus of the Wellness team is to identify and help members understand their risks and assist members in decreasing those risks.

AultCare Wellness strives every day to lead our community to improved health through coaching, goal setting, education, encouragement, and support. Depending on the arrangement with each contracted company, AultCare Wellness provides on-site health fairs which include labs, blood pressure, body mass index, body fat percentage, waist circumference, an online Health Risk Assessment, and an assigned health coach. Visits with the health coach are one-on-one via in-person, telephonic, or a group setting. Additional services are provided upon request and as the need arises.

The AultCare Wellness services are provided to all PrimeTime Health Plan enrollees as well as at an additional cost to employer groups in our community.

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Click the infographic to learn more about My Plate - the latest nutritional guidelines.

Video: Chylece Head- her AultCare Wellness team experience

Video: How to Tone Your Thighs

Video: Healthy Recipes with AultCare Dietitian

The Pharmacy Benefit Management team works alongside prescribing physicians to make sure patients receive the most appropriate, lowest-cost medications to ensure the best outcome.

AultCare’s Pharmacy team made up of clinical pharmacists, pharmacy technicians, data analysts, and medical directors to help patients navigate their formularies and answer medication-related questions.

Through use of flexible, custom formularies and plan designs, members can expect to receive high quality, low net cost medications from the Pharmacy program. This team of local experts works with a national Pharmacy Benefits Manager to power negotiations for drug costs. Members receive integrated and tailored Pharmacy services when they utilize other programs within AultCare’s Care Coordination.

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Click the label to learn how to read Over-The-Counter (OTC) drug labels via the FDA.

Our Pharmacists are available to take questions. Email a Pharmacist today.

The Population Health Management (PHM) team is now Primary Care Connection (PCC), a team of nurses who is the link between members, providers, and the health plan. By working with you, your Primary Care Physician (PCP) and your health plan, we can effectively coordinate your care. We will assist with education, prevention, acute, and chronic health issues. We are ready to help you navigate the healthcare system to ensure the best possible care and treatment.

Our Primary Care Connection (PCC) program focuses on providing patient-centered, accessible, comprehensive, and coordinated care. Our nurses connect with members over the phone or face-to-face for as long as needed. We offer education to those dealing with chronic and acute conditions along with additional information and resources to ensure our members’ needs are met.

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Video: Dr. Wymslo discusses the value of Preventive Care.