Health Management Services

The Utilization Review and Case Management Program at TriSurant, initiated in 1985, meets the needs of our clients arising from ongoing changes in the healthcare delivery system. In 1993 our Health Management Services Department was certified as a UR Agent by the State of Texas.

Our Health Management Services staff pre-certifies all inpatient admissions, client-specific outpatient procedures and ancillary services, and handles the administrative requirements for pre-certification, pre-determinations and appeals to ensure medical necessity and appropriate level of care and PPO steerage. Our Case Managers coordinate activities and referrals to and from the Disease Management Program.

The HMS Case Managers work with patients, providers and clients to determine appropriate levels of care for the most cost effective and medically necessary services for the patients. Steerage to network providers and negotiations with out-of-network providers assure cost savings for the client and the members.

The Utilization Management/Case Management system interfaces with our claims processing system. The Health Management Services staff interacts with other TriSurant departments to provide data for accurate client reporting and Stop Loss support.

TriSurant offers Mental Health Case Management services. This review program is from the stance of a Patient Advocate. Patients may have limited resources through their benefit plan and may or may not understand the nature of the illness, but often will have only the most cursory understanding of particular plan coverage and administrative guidelines. The role of this program is to assist both the patient and the doctor or treatment professional in understanding that flexible benefits do exist. This means that treatment is at an appropriate level of care.