Managing Your Care

In most health care scenarios, you can take the time necessary to discover the most effective and efficient way to manage your care. The Fund provides case management services to help you make those treatment decisions. But there are situations in which you'll need to take immediate action, such as in an emergency.

If you're covered under the Regular Plan or Low Option Plan and incur charges as the result of a medical emergency, your reimbursement level will depend on whether you received care from network or non-network providers. If, as a result of an emergency, you didn't have time to contact a network provider, the Fund may review and reprocess a claim you submit for non-network services.

Urgent Care
If you have a situation that isn't life-threatening but does require immediate medical care, it's called an urgent condition. Here are some examples:

• Back pain;
• Ear infections;
• Minor burns;
• Simple bone breaks (e.g., toe, finger);
• Sprains; and
• Urinary tract infections.

If you're in a PPO network area and want to receive the higher, network level of benefits, you must seek urgent care from a network provider; otherwise, you'll receive the lower, non-network level of benefits.

Case Management
Case management is a voluntary program that will help you manage your care so that you'll receive the most efficient and effective services. The Fund offers case management to all plan participants. If you or a covered dependent is ill or injured, a case manager will coordinate your medical care, services, and treatment, always with direction from the ordering physician. Integration of multiple services, access to care and continuity of care will be improved as you move from illness and return to better health. In addition, you're welcome to call the case manager to discuss any concerns about your care or coverage.

If your diagnosis indicates that you may benefit from case management services or if you or a covered dependent files a claim for a major illness or injury (such as a stroke or a serious motor vehicle accident), you may be contacted by the case manager. He/she is available to monitor your care and recovery, in cooperation with your health care team. The case manager will develop a customized treatment plan based on your needs and, in many cases, facilitate and negotiate the most cost-effective treatment or services for your care.

Certain treatments or care - such as home infusion services, home nursing visits, inpatient skilled nursing facility placement and admission to a hospice program - must always be coordinated through case management. Case management won't increase or exceed the benefit limits available to you under your medical plan but may help negotiate rates or establish an alternate treatment approach.