True Health New Mexico has a Case Management Program to help members and their caregivers who have multiple or complex medical problems. Our Case Managers:
- Coordinate your medical information and treatment alternatives.
- Identify any resources needed to support your care.
- Work with you, your caregiver, and your healthcare provider. Case Managers guide you into an appropriate plan of care designed to help you regain optimum health.
- Navigate the complex process of organ transplant services and care.
Advantages of Case Management
- Each Case Management nurse provides personalized service to you, your family, and your healthcare providers to help coordinate care.
- Your Case Manager will help plan the complex array of services your special case needs.
- Your Case Manager will help ensure that you receive care efficiently and effectively.
- Your Case Manager will provide health education to empower you and your family. You’ll learn how to self-manage aspects of your care, as your provider deems appropriate.
Is Case Management Right for You?
You may benefit from our Case Management Program if you have one of these conditions or needs:
- Chronic medical conditions
- Conditions requiring complex home equipment or medications
- Organ transplant
- High-risk maternity
- Conditions requiring community resources and social services
- Behavioral health issues
- Complicated hospital discharges
Care Coordination Services
The Case Management team is able to provide additional support to you in the following ways:
- Follow up with you after a hospitalization to ensure aftercare is in place.
- Help you troubleshoot issues with obtaining medical supplies and prescriptions and ensure you receive care efficiently and effectively.
- Help you find providers and services within the True Health New Mexico network.
Transition of Care Program
If you are receiving an ongoing course of treatment from an out-of-network provider at the time of your enrollment with True Health New Mexico, you may be eligible to continue to receive services from this provider and have the services covered under your True Health plan. This is called transition of care.
Transition of care covers certain medical conditions, including:
- Pregnancy in the second or third trimester
- Chemotherapy or radiation therapy
- Recent major surgeries
- Hospital confinement
- Other conditions
To be considered for transition of care coverage, you must apply for it either at enrollment or no later than 30 days after your effective date of coverage. True Health New Mexico will make determinations for transition of care based on established medical criteria.
Get started by downloading our Transition of Care Guide on our Member Forms and Documents page. There is a form for you to complete and submit at the end of the guide.
Our Utilization Management & Prior Authorization Procedures
Utilization management (UM), sometimes called utilization review, is the evaluation of the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities under the provisions of your health plan.
- Most routine services, such as a visit with a PCP or specialist, do not need a prior authorization (PA). You usually need a PA for certain procedures or surgeries, exceptions to the formulary (drug list), and requests for services outside of our provider network.
- When you do need a PA, your provider makes the request for you. The PA process can take place before the service occurs in planned and non-urgent situations, at the time of an urgent situation, and after receiving care.
- If you are admitted to a hospital, the facility must tell True Health New Mexico. It is up to you and your provider to see that all PA procedures outlined by True Health New Mexico are followed correctly. These procedures are in your Evidence of Coverage/Member Handbook.
- When a PA is required, True Health New Mexico uses doctors who are licensed in New Mexico to conduct the reviews and to make determinations (decisions).
- True Health New Mexico nurses review all inpatient services as they occur to ensure that you are receiving the best service for your level of care.
- We offer case management services to True Health New Mexico members who have complex healthcare needs. This ensures that you receive appropriate and timely care.
- We also offer transition-of-care services for up to 30 days. These services are for when you are being treated by a non-contracted provider at the time of your True Health New Mexico enrollment.
- Find complete utilization management information in your Evidence of Coverage/Member Handbook.