Excel will design or follow the existing Telephonic Case Management (TCM) program including the option to interface with the current claims system, which allows the nurse to work closely with the claims team. TCM services assist in cases that rise to the level that require medical intervention and work in a collaborative environment with the UR and claims department.
TCM Nurse will always perform the following actions:
- Monitor medical treatment and provide active intervention to insure appropriate progress toward restoring wellness and productivity.
- Authorize ACOEM/MTUS approved medical request.
- Identify and refer to UR when appropriate.
- Provide ongoing follow up and management as needed with all parties.
- Maintain file note communication with claims professional.
- Coordinate onsite (Field) RN visits when appropriate.
New Referral Received
- TCM reviews referral information
Contact Made with IW
- Within first 48 hours, subjective history taken from IW.
- Referral to network provider is made or if injured worker has already had initial evaluation, TCM ensures provider is within the network and re-directs care if necessary.
First Report and Medicals Obtained and Reviewed by TCM
- ODG/ACOEM/MTUS guidelines are reviewed
- Plan of action (POA) is formed
- Update provided to the adjuster and any pertinent parties on the file
Subsequent Follow-Up Evaluations
- Following each medical appointment, TCM obtains follow up reports and work status information and updates POA accordingly.
- TCM sends periodic inquiries to the provider to obtain more case specific information such as comprehensive treatment plans, RTW dates, P&S date etc.
- TCM maintains contact with the IW to monitor progress toward RTW and ensure continuity of care.
- TCM provides updates of work status, medical condition and POA to adjuster and any pertinent parties on the file.
- If surgery or an acute hospitalization arises, refer to Field Case Manager if approved. If not, provide appropriate discharge planning and post op care follow through.
Return to Work
- TCM will obtain regular work status updates from the provider and attempt to facilitate RTW. If IW is unable to return to full duty, TCM will forward a copy of the IW’s job description to the provider and push for a modified work release. If IW is unable to RTW per guidelines, TCM will inquire of the provider what the functional limitations are that preclude a RTW. From this, the TCM will attempt to parlay the IW abilities into a suitable modified work position by coordination work restrictions with the employer.
Treatment Authorization Requests
- TCM reviews all treatment authorization requests from the provider
- Authorization requests for treatment are given to the provider via written letter if it falls within ACOEM/MTUS approved guidelines. If a treatment request does not fall within guidelines, but seems reasonable, TCM will confer with the adjuster on the request and may provide authorization based on their discussion followed by written authorization.
- All authorization requests that do not fall within guidelines or not deemed reasonable by adjuster/TCM will go to UR for review. TCM will follow up on the determination.
- When a treatment request is authorized, TCM will ensure that the provider and all ancillary providers fall within the network.
- TCM will obtain diagnostic test results and coordinate appropriate treatment. Channeling will be coordinated within the network, when applicable.
- TCM will follow case until the IW is released to work.
- TCM to close file if assigned to Field Case Manager.