CU Care Management Matrix
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- Garry McDowell
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1 CU Care Matrix Group Name(s) Exclusive Exclusive Exclusive High Deductible HSA Compatible and Extended Capitated/FFS Facilities Capitated for physician only UCH Childrens FFS FFS FFS Poudre Valley Center of the Rockies Greeley Emergency & Surgery Center Memorial Hospital The Childrens Hospital at Memorial Only Boulder Womens Care Orders/Deliveries (lab and procedures) can be done at Boulder Community or Boulder Womens Care for CU ( and require referral as Boulder is OON for them) Pre Authorization Phone: (303) Fax: (303) Phone: (970) Fax: (970) Phone: (719) Fax: (719) Phone: (800) Fax: (800) Any service reviewed by in matrix: (800) Inpatient Pre scheduled Inpatient Procedures LTAC/Rehab/SNF Utilize HMO Accupuncture Utilize HMO Alcoholism/Drug Addiction/Residential Treatment Utilize Behavioral Use Landmark Behavioral Behavioral Behavioral Behavioral Appeals First and Second Contact Dr. Jeff Rumph Contact Dr. Rich Penaloza (303) PCR speaks with Managment physician prior to issuing denial
2 Ambulance/Air Ambulance Utilize HMO Autism Utilize HMO for Behavioral Issues CU Care Matrix Behavioral Utilize Behavioral Breast Reduction Case Chiro Utilize HMO Behavioral (800) Use Landmark Requires PA review for all plans No CM/DM purchased for CU Exclusive members Continuity of Care receives CoC requests for N,C,S and contacts for continued services. Teresa Corwin Vine Managed Care Specialist (303) Lynn Riippi, RN Exclusive Case Manager (303) Dental Surgery/Appliances Disease Programs Direct calls to Lynn Riippi, RN in (303) DME Utilize HMO AIM excluded for all CU members Eye Surgery (Refractions Utilize HMO ) Emergency Room Hearing Aids Considered DME Utilize HMO High End Imaging MRI, MRA, CT, PET There is no AIM review for ANY CU plan Non exclusive plans, review procedures on PA list only by
3 CU Care Matrix Home /Home Infusion Utilize HMO Use network Home Self Injectable UCH UCH UCH Authorization contact at UCH: Rachel Boggs, PharmD Phone (720) Hospice (home and inpt. Per current guidelines hospice) Utilize HMO Inpatient ER admit OON Exclusive Plans does review, we repatriate to Exclusive facilities by region contact appropriate network contact LTAC Long Term Acute Care Utilize HMO Maternity Utilize HMO Boulder Community in network for maternity for only Applies to Exclusive Plan members, includes pre term labor NICU Obs vs 1 day Out of Scheduled Outpatient Infusion MD Office or Infusion Center Boulder IN for deliveries/gyn procedures and maternity care only (/ would require approval from UMA/MedNet) (Contract specific) Must be reviewed prior to services UCH UCH UCH pre cert list and drug prior auth list. For Exclusive Plans only: IV iron products, IV antibiotics, zoledronic acid, pamidronate, and cosyntropin also require authorization.
4 CU Care Matrix Outpatient Procedures Surgery Prescription Drugs Retail Outside of UCH Utilize HMO Rehabilitation Utilize HMO Repatriation of sick newborns from Boulder Repatriation to CU In Facility For Exclusive plans only: requires preauthorization for Hysterosalpingogram and J7321 Hyalgan/Synvisc for all sites including the knee. Exclusive : See Repatriation contacts above N/A Contacts for Transfer to Facility: Exclusive : DocLine Transfer Center University of Colorado Hospital and Memorial Hospital Phone: Children s Hospital Transfer Center Phone: Exclusive : Phone: Exclusive : Phone: Skilled Nursing Facility Utilize HMO
5 CU Care Matrix Sleep Studies (CPAP supplies considered DME) Exclusive plans review for all sleep services. / keep in house. National Jewish/home sleep study. Home sleep study preferred. Non exclusive plan: reviews Multi Sleep Latency test only There are no other sleep services on the PA list for non AIM groups. Review for the place of service if there is a contract requirement. CPAP supplies considered DME and authorized by rather than AIM. Specialist Referrals PCP referral required to see specialist both in and out of regional networks (N/C/S). UPI will send spreadsheet to UM Intake for members referred outside of regional network, services requiring authorization, or OON services has authorized. Specialty Drugs in Office For Exclusive plans only: Plan requires preauthorization for J7321 Hyalgan/Synvisc for all sites including the knee. Transplant evaluation Transplants Utilize HMO Exclusive Utilization Coordinator Authorization not required. Referral from PCP is required to specialty clinic. Transplant Team (888) CU Contacts CU Exclusive Contacts ( )
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