NY Manual
SHP Manual

New York Provider Manual
11.2 Urgent Care | 12.2 PCP-Directed Care

12. Medical Management

12.1 Program Overview

The Healthfirst Medical Management Program has been designed to maximize the quality care delivered to Healthfirst members. The program focuses on assisting providers in collaboration with members/caregivers in planning for, organizing, and managing the healthcare services provided to Healthfirst members to promote member health and well-being. Information and data collected through medical management procedures are used by the Medical Management department to properly allocate resources and to foster efficient and effective care delivery. The Medical Management program emphasizes collaboration with network providers, contracted vendor organizations, and other Healthfirst staff to ensure that high-quality healthcare is provided at the most appropriate level by the most qualified panel of providers.

The Medical Management department is responsible for the following areas:

·     Authorization and Notification Processes
·     Continuity of Care
·     Concurrent and Retrospective Review
·     Care/Disease Management

Each of these program components, with the exception of Care/Disease Management, is discussed in detail in the following subsections of Section 12. The Healthfirst Care/Disease Management Program is described in Section 13 of the Healthfirst Provider Manual.