Thank you for being a member of Centers Plan for Healthy Living. As a member, we want to provide you with the quality service that you deserve and is specific to your individual needs. We recognize that the more information we provide, the better informed you, your family and your physicians will be to make the right decisions regarding your healthcare.
You are part of our family and we want to hear from you. Please call or send us any comments you may have.
It is our pleasure to serve you.
Care Management Services
When you enroll, you, your Doctor, and the CPHL Care Management Team, will work together to develop a plan of care that meets your needs and is medically necessary. Medically necessary services shall mean services that are necessary to prevent, diagnose, correct or cure conditions that cause you acute suffering, endangers your life, results in illness or infirmity, interferes with your capacity for normal activity or threatens some significant handicap. The service plan is a written description of all the services you need. It is based on your Care Team’s assessment of your health care needs, the recommendations of your Doctor, and input from you and your family or caregivers. The service plan is a summary of the services you will receive, and is based on the individualized care plan.
You will receive a copy of your service plan and any changes in your service plan will be given to you in writing. Your Care Management Team will continuously monitor and evaluate your health status and care needs. As your needs change, your plan of care will be changed to make sure that your service plan includes all of the services you currently need. This will include increasing or decreasing services and changing the services provided. (Please see Requesting Additional Services or Changes to the Care Plan Service and Authorization for Services later in this section). A formal reassessment will occur at least every one hundred and eighty (180) days. To make monitoring your care and evaluating your needs easier, it is important that you talk with the members of your Care Management Team to let them know what you need. It is also important to let them know when you have used a non-covered service. See, Section 4, list of Covered and Non-Covered services.
By doing so, your Care Management Team will be able to manage your care in the best way possible. A member of your Care Management Team will arrange the covered services that you need. This includes setting up transportation to and from all non-emergent medically related appointments, providing you with home delivered meals, and arranging for home care. A member of your Care Management Team will also assist you with accessing noncovered services if you need them to. This means, for example, that your Care Management Team will help you identify providers of non-covered services and will help you schedule your appointments with your doctor, or with a laboratory, and will provide for transportation to and from these appointments . It could also mean that your Care Management Team would assist you with accessing hospital outpatient services.
Grievances and Appeals
To view full Grievances and Appeals click here.
Centers Plan for Healthy Living Utilization Management Service Authorizations is based on the premise that quality medical care is the single-most-important element in delivering health care services. It is a coordinated and comprehensive program designed to monitor access to health care services to members.
Utilization Management decisions made by CPHL are based solely on the necessity and appropriateness of care and service.
- CPHL does not compensate those responsible for making UM decisions in a manner that permits them to deny coverage for medically necessary and appropriate covered services.
- CPHL does not offer our employees performing UM reviews incentives to encourage denials of coverage or service, and does not provide financial incentives to providers to withhold covered health care services that are medically necessary and appropriate.
- CPHL emphasizes the provision of medically necessary and cost-effective delivery of health care services to members and encourages the reporting, investigation, and elimination of under utilization.
To view referral form click here