It is also responsible for coordinating and monitoring access to care, developing programs, and evaluating the quality of healthcare services in accordance with guidelines from the Department of Defense, Lead Agent, Regional 12, and Health Affairs.
Specialist Referrals– The Primary Care Physician (PCP) may request a consultation from a participating specialist physician at any time. The PCP determines the number of visits authorized. Specialists may include – Gynecologist, Radiation Oncologists, Ophthalmologists, Pediatric Ophthalmologists, Retinologists and Allergists etc.
Emergency Room Services –An emergency medical condition is defined as a condition that manifests itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following:
Out-of-Plan Referrals– All out-of-Plan referrals require Plan prior authorization at Guam. These requests are reviewed on an individual basis. Determinations are made based on the patients medical needs and the availability of services to meet these needs within the provider.
Tertiary Care Services– All referrals to plan tertiary care centers are reviewed on an individual basis. The members medical needs and the availability of requested services within the non-tertiary care network are taken into consideration.
Discharge Planning – Patients who require continuing care after release from the hospital are identified and the appropriate services are arranged through participating home care, medical equipment and other providers.
The facility’s Utilization Management Program may need continued review on a periodic basis in order to keep it on par with the model Utilization Management Program as described by the HealthCare Advisory Council. In keeping with these lines, the program is