Page 8 - Commercial Group Member Guidebook

Ways We Manage Your Care

MANAGED CARE PLANS ARE DESIGNED TO PROVIDE ACCESS TO HIGH-QUALITY CARE
WHILE CONTROLLING HEALTH CARE COSTS.

How do we accomplish this?
ConnectiCare uses utilization management programs and procedures to evaluate the quality, medical
necessity, and efficiency of covered health care services. Decisions about whether ConnectiCare will pay for
care are made using medical protocols developed from national standards with local physician input. We do
not reward or offer financial incentives to physicians or other individuals making decisions regarding whether
we will pay for health care treatments, drugs and supplies.

ConnectiCare requires pre-authorization of selected services
Your physician may seek this authorization, but it is your responsibility to be sure it has been approved before
you get the care or service. And, except for the Point-of-Service (POS) plans and Preferred Provider
Organization (PPO) plans, all health care services and supplies must be ordered, rendered and supplied by
a participating practitioner or provider facility, or the service or supply may not be covered.

When a new treatment or supply becomes available or a new use of an existing treatment or supply becomes
available, we review the treatment or supply to determine whether it should be covered under the plan.

ConnectiCare provides concurrent review
When you or your dependents are admitted to the hospital or a skilled nursing facility, a ConnectiCare nurse
case manager reviews the care you are receiving and may speak with your caregivers during your stay. This is
called concurrent review. The purpose of concurrent review is to ensure that the services you are receiving are
appropriate and that there is coordination and planning for your discharge home. Concurrent review is also
conducted if you receive home care services.

Finally, we may use outside companies to manage and administer certain categories of benefits or services
provided under this plan. For example, for some benefit plans, mental health and substance abuse care
services are administered by OptumHealth Behavioral Solutions.
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Plan exclusions and non-covered services

As with all health care coverage, there are some services that are excluded. However, exclusions do vary from
plan to plan. For details on plan exclusions or to determine if a specific service is not covered, please contact
Member Services at (860) 674-5757 or 1-800-251-7722 or via e-mail at info@connecticare.com. Once you’re
a member, you can e-mail us through our secure messaging online, or refer to the appropriate Membership
Agreement/Certificate of Coverage for the plan in which you are covered.

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