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Ensure the Effective Utilization of Healthcare Resources

 

TruCare provides a comprehensive, integrated Utilization Management (UM) module which supports the ability to synchronize with administrative systems, provider portals and the full scope of operational processes needed to maintain regulatory compliance, integration with clinical guidelines and automated workflow processing. TruCare Utilization Management integrates prospective, concurrent and retrospective data on the same platform as the member’s care management initiatives. Automated processing rules, work queue assignments and next steps in the review process can be defined for specific services, member populations or other organizational alignment of administrative or clinical teams. The TruCare UM module eliminates redundancy and ensures healthcare resources are utilized consistently, efficiently and effectively.

 

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Casenet Overview

 

TruCare

 UM Features

 Authorization Processing

Appeals and Grievances

The TruCare UM module seamlessly operates with the TruCare Care Management, TruCare Home and Community Services, and TruCare Disease Management modules, establishing a single platform that can be utilized across an organization’s entire membership.

 

TruCare Utilization Management offers:

 

  • Total Health Management – TruCare Utilization Management allows users to swiftly and effectively refer members to care management programs as appropriate.
  • Pre-authorization/Pre-certification – Effectively streamline the creation of pre-authorizations and pre-certifications with simple, automated and clinically relevant workflows.
  • Concurrent Review and Discharge Planning – Manage costly inpatient care by enabling users to perform continued stay reviews and assist with discharge planning in a timely and efficient manner.
  • Documentation & Letter Generation – Structured notes, available throughout the UM workflow, enable effortless documentation. Users can easily generate correspondence based on determination.
  • Prescreening – Quickly determine member eligibility and authorization requirements prior to completing authorization submissions using the TruCare Prescreen tool.
  • Organization-Specific Business Rules – Establish succinct business rules to support utilization management including user notifications and automated approvals and authorizations.

Automated authorization processing is available using the TruCare configurable, business rules engine which supports client-defined UM processing. The TruCare Business Rules Engine (BRE) can drive internal and external authorization workflows based on client-defined rules. Rules can be associated to the member and their unique plan requirements using the Differential Care Management framework which is integrated with the TruCare UM business rules.

TruCare Appeals and Grievances capabilities enable organizations to easily structure the end-to-end appeals & grievances process, maintaining adherence to plan policy and all relevant regulatory requirements, and fostering strong relationships with providers and consumers.

 

The TruCare Appeals and Grievances functionality is integrated within the UM workflow and authorization record. Appeal details, work tasks, documentation and correspondence capabilities are provided directly within the associated authorization record and are available for both visual reference and reporting by authorized users.