Preventive Health Services

Our Utilization and Case Management Commitment

All Optimum HealthCare Inc. Utilization Management and Case Management staff and practitioners who make UM decisions affirm the following to our members, our providers, our practitioners and all federal and state regulatory agencies:

• UM decision making at Optimum HealthCare Inc. is based only upon the appropriateness of care and services and the existence of coverage;
• Optimum HealthCare Inc.  does not specifically reward practitioners or other individuals for issuing denials of coverage or service care;
• Financial incentives for UM decision makers do not encourage decisions that result in underutilization;
• Optimum HealthCare Inc. does not in any way participate in any practices that would be considered discouraging appropriate utilization or encouraging underutilization.
• Optimum HealthCare Inc. does not use incentives to encourage barriers to care and service.

Preventive Health Guidelines:

Optimum HealthCare Inc. believes that preventive health measures are a key to good health for our members. We will be measuring how well we do in delivering health care that includes preventive health activities. Optimum HealthCare Inc. has adopted guidelines to help us in deciding what type of screening tests our members should receive. The Medical Advisory Board/ Quality Committee has adopted the U.S. Preventive Services Taskforce Guidelines. The USPSTF guidelines are based on nationally recognized standards of care. The guidelines are available to providers and members requesting a hard-copy version.

Optimum HealthCare Inc. will review the preventive health guidelines annually and make the necessary updates to reflect any changes in recommendations regarding screening, counseling, and preventive services. If changes occur during the year to our Preventive Guidelines or Immunization Schedule, they will be updated on Optimum HealthCare Inc. website for your viewing. These guidelines can be referenced on the website for the Agency of Healthcare, Research and Quality at http://www.ahrq.gov/clinic/uspstfix.htm

In addition, the following reference materials are available.

• A complete copy of the guidelines PDF format; this version includes recommendations for both children and adults;
• A reference grid for preventive health services for both children and adults;
• A preventive health timeline for adults;
• An immunization schedule for adults by age, or by medical condition.

Optimum HealthCare Inc. has also adopted the following guidelines:

• ADA , Standards for the Diagnosis of Medical Care in Diabetes-2006;
• ACC, Standards for the Diagnosis and Management of Chronic Heart Failure (2005);