Our quality standards

Case management: Helping you manage all the moving pieces

Healthcare can be overwhelming. Our case managers can help make it easier. Your providers know how to help you with your care. It helps if you know how to care for yourself, too. That’s what our case managers do.

As an Amerigroup District of Columbia, Inc. enrollee, you can get many different types of services. Your case manager works with you and your provider to set up a plan of care. You may already be working with a case manager and know how to contact them.

If you need case management services or need help contacting your case manager, call us at 800-600-4441 (TTY 711).

Our case managers may also call if:

• You or your provider thinks case management might help you.
• You’ve just gotten out of the hospital and need help with follow-up visits to other providers.
• You’re going to the emergency room (ER) often for non-urgent care that could be handled by your provider.
• You call Nurse HelpLine and need more follow-up for ongoing care.
• You have serious physical problems and need more help.
• You have mental health problems and need more help working with all of your providers.

Your case manager can also help with the following:

• Setting up healthcare services.
• Checking your plan of care.
• Getting referrals and prior authorizations (approvals).

If we call you, a nurse or social worker will:

• Always identify themselves with their name, title and position with Amerigroup DC.
• Tell you about what we offer.
• Talk to you about your health and how you’re handling different parts of your life.

Utilization management: How we make choices on care and services

Sometimes, we must choose how we pay for care and services. This is called Utilization Management (UM).

Our UM program:

• Looks at what, when, and how much of our services are medically needed.
• Always strives for the best possible health outcomes for our enrollees.

Our UM program does not:

• Tell doctors to withhold or give you fewer services limiting or denying care.
• Reward doctors for limiting or denying care.
• Stop certain people from getting services.

Getting in touch with our Utilization Management staff

Some Amerigroup DC services and benefits need prior approval. This means your provider must ask Amerigroup DC to approve the services they want you to have. Services that don’t need approval are:

• Emergency care
• Care needed after a hospital stay

Our Utilization Review team looks at approval requests. The team decides if:

• The service is medically needed.
• The service is included in your Amerigroup DC benefits.

What should you do if Amerigroup DC won’t pay for the care you think you need? You or your provider can ask us to take another look. We’ll let you and your provider know when we get your request. You can ask us to take another look at services that:

• Are not approved.
• Have been limited in the amount or length of time from what was requested.

Do you have questions about an approval or a denial you got? Call Enrollee Services at 800-600-4441 (TTY 711). Our Utilization Review team can help answer your questions.

Appeals

If you believe your benefits were unfairly denied, reduced, delayed, or stopped, you have a right to file an appeal with Amerigroup DC.

• Grievances, Appeals, and Fair Hearings Process - English
• Grievances, Appeals, and Fair Hearings Process - Spanish

Your opinion matters

Every year we survey our enrollees about the benefits we offer. If you get a survey in the mail, by email, or by phone, please complete it. Please help us make your plan better.

New technology in medicine and care

To make sure we are always using the latest medical treatment and equipment to help you feel your best, our medical director and providers look at all the latest medical changes. They look at the following:

• Medical treatment and services
• Behavioral health treatment and services
• Medicines
• Equipment

They also look at the most up-to-date medical and scientific writings. With all this data, they consider:

• If the changes are safe and helpful.
• If these changes offer the same or better results than what is used today.

This work is done to help us decide if a new treatment or care should be added to your benefits.

You have rights and responsibilities

As an Amerigroup DC enrollee, you have rights and responsibilities. They are listed in your enrollee handbook. Do you want a printed version of your handbook? Call Enrollee Services at 800-600-4441 (TTY 711).

Your benefits and how to get medical care

Are you looking to learn more about our services and benefits? Grab your enrollee handbook. You can read about the following:

• Preventive healthcare: Find out how to help prevent many health issues and how to live a healthier life.
• Preventive healthcare for women: Learn how to access women’s health specialists for regular and preventive healthcare services.
• Benefits and access to care: Find out more about your benefits and how to get medical care.
• Language help: Learn how to get our information in the language you use at home.
• Pharmacy: Find out about your benefits and how to get the medicines you need.
• Case management: Partner with a case manager to learn more about ways to get care for your health issues.
• Enrollee rights and responsibilities: Read about your rights and responsibilities.
• Notice of Privacy Practices: Learn more about how we keep your private information safe.
• Medical necessity: Find out how we decide if care is right for you based on the right coverage and levels of care and service.
• Advance directives: Learn more about your right to use an advance directive (living will), to have one on file or on hand if you can’t tell others about the care you want to keep you alive. Your provider has advance directive forms and more information.

Behavioral health (mental health and substance use disorder services)

Sometimes, dealing with all of the tasks of a home and family can lead to stress. Stress can lead to depression and anxiety. It can lead to marriage, family, and parenting problems. Stress can also lead to alcohol and drug abuse.

If you or a family member have these problems, you can get help. Call Amerigroup DC Enrollee Services at 800-600-4441 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m. Eastern time. You can get the name of a behavioral health specialist who will see you if you need one. You can also find a provider with our Find a Doctor tool.

Your benefits include many medically needed services, such as:

• Inpatient behavioral health services
• Outpatient behavioral health services
• Partial hospitalization
• Treatment and rehabilitative services

See your enrollee handbook to learn more about your benefits.

You don’t need a referral from your primary care provider (PCP) to see a behavioral health specialist in your plan.

There are some treatments and services your behavioral health specialist must ask Amerigroup DC to approve before you can get them. For information about services that need preapproval, please see your enrollee handbook.

If you have questions about referrals and when you need one, contact Enrollee Services at 800-600-4441 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m. Eastern time.

Our Notice of Privacy Practices

This notice tells you about how we may use and share your health data. It also tells you how to get this data. The notice follows the Privacy Rule set by the Health Insurance Portability and Accountability Act (HIPAA). Our Notice of Privacy Practices is in your enrollee handbook as well as online. Call Enrollee Services at 800-600-4441 (TTY 711).

Not a kid anymore? It may be time for a new PCP or behavioral health provider.

It’s important for you to get the right care from your providers. As an adult, you can choose to change from a provider who cares for children or teens to one who focuses on treating adults. This includes providers for physical and behavioral health. We can help if you want to change. We can also help you transfer your medical records.

Start by asking your current primary care provider (PCP) or behavioral health provider for a recommendation for a new adult PCP or behavioral health provider. We’re here to help, too. You can change your PCP or behavioral health provider at any time. It’s easy with our Find a Doctor tool. Or call Enrollee Services at 800-600-4441 (TTY 711).