Complex Condition CARE, Complex Condition CARE +, or GenerationYou CARE Support Referrals. During the Prior Authorization review process, cases are analyzed for a number of criteria used to trigger case-to-case management for review. Complex Condition CARE, Complex Condition CARE +, or GenerationYou CARE Support opportunities are identified by using system-integrated, automated, and manual trigger lists during the Prior Authorization review process. Other trigger points include the following criteria: length of stay, level of care, readmission, and utilization, as well as employer referrals or self-referrals. Our goal is to intervene in the process as early as possible to determine the resources necessary to deliver clinical care in the most appropriate care setting. Retrospective Review. Retrospective review may be conducted upon request or at the Plan’s discretion, and a determination will be issued within the required timeframe of the request, unless an extension is approved. Retrospective reviews are performed according to our standard Prior Authorization policies and procedures and a final determination will be made no later than 30 days after the request for review. CARE PROVISIONS Complex Condition CARE Complex Condition CARE is available to all Covered Persons. CARE nurse managers evaluate and coordinate post-hospitalization needs for members who have a high probability of subsequent readmission within 30 days. Participants are identified based on historical claim factors and current admission information, including, but not limited to: • unplanned readmission within the past 30 days or multiple unplanned admissions within the past 6 months. • length of stay. • complex diagnoses or comorbidities pertaining to, but not limited to, cancer, cardiovascular conditions, kidney failure, pulmonary conditions or infections, End Stage Renal Disease (ESRD), or liver/pancreas/gastrointestinal surgery. • management of catastrophic and complex behavioral health and substance use disorders and support for identified members utilizing Inpatient/rehabilitation/residential facilities. Emerging CARE Emerging CARE focuses on Covered Persons who are showing health behaviors that could lead to movement to a high-risk status. UMR CARE Coordinators will reach out telephonically to Covered Persons to assist them with health management. Outreach may be due to, but not limited to, frequent Emergency room visits, discharge support, Medical Specialty Medications, denial and appeal support, preadmission counseling for Inpatient and Outpatient elective surgeries, and behavioral health/substance use disorder member and family support. In addition to telephonic outreach, members are able to reach clinicians by calling the number on the back of their identification cards. Ongoing Condition CARE Ongoing Condition CARE identifies those individuals who have certain ongoing conditions and would benefit from this program. Specially trained CARE nurses work telephonically with Covered Persons to help close gaps in care and improve self-management of their condition(s). Program participants are identified through predictive modeling. Our unique approach to Ongoing Condition CARE identifies individuals with one of the following 22 targeted conditions: • Neuromuscular / Autoimmune Disorders: ALS, Multiple Sclerosis, Myasthenia Gravis, Rheumatoid Arthritis • Cardiovascular Disorders: Hypertension, Heart Failure, Coronary Artery Disease • Respiratory Disorders: Asthma, COPD • Behavioral Health Disorders: Depression and General Anxiety Disorder (GAD is a comorbidity) • Blood Disorders: HIV, Hepatitis C, Sickle Cell Anemia -81- 7670-00-413597