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Integrated Healthcare Management

The Integrated Healthcare Management (IHM) Department conducts all clinical operations for BCBSMT.  The staff of IHM includes board-certified physicians, registered nurses, licensed behavioral health specialists, pharmacists, and functional business experts.  Our team follows national clinical guidelines and member health insurance benefit policies to determine coverage eligibility for medical and pharmacy, hospitals, and facilities.  By improving patient education, provider coordination, and access to services, IHM helps members get the most from their health care dollars.

    

IHM working teams perform the following functions:

  • Care Coordination Team – Registered nurses and licensed clinical social workers serve as a single point of contact for patients, educating them in their health behaviors to help reduce complications and improve outcomes.
  • Utilization Management Team — Using established medical national guidelines, our nurses and behavioral health clinicians partner with providers to ensure that inpatient health care services, procedures, and facility use are appropriate, timely, and effective.
  • Appeals Team — Functional business and clinical experts review and research all contract and benefit appeals that are requested by a member, provider, or facility.
  • Pharmacy Team – A registered pharmacist and pharmacy technician manage utilization of prescription drugs, administer formularies, and coordinate services with our pharmacy benefit manager, Prime Therapeutics.  They also provide consultative services to help employers develop individualized pharmacy benefit programs.
  • Support Team — Functional business experts support our clinical teams by preparing clinical requests and communicating clinical decisions back to members and providers.
– Registered nurses and licensed clinical social workers serve as a single point of contact for patients, educating them in their health behaviors to help reduce complications and improve outcomes.
 
 
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