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Care Counseling Program and Services

Care Counseling from Pacific Health Alliance provides members the ability to call one number for services they need when they need them the most.  Care Counseling services include:

  • Member assistance in locating the right healthcare resources/li>
  • Easy Access to trusted clinical and social services
  • Simplification for coordination of benefits and care options
  • Viable alternatives for more cost efficient services
  • A source for good accurate medical information
  • Guidance for members and their families through the healthcare system

 

The Pacific Health Alliance Care Counseling Service has several components to help your members and your fund make the right health care decisions.  In addition to providing a personal advisor to help members better understand their health care needs, the Pacific Health Alliance Care Counselor will:

  • Help members find a primary care physician who is part of the network
  • Identify lower cost providers offering requested services
  • Gain convenient access to quality care
  • Obtain referrals to provider, facilities, and other services
  • Help the identify the appropriate level of care for their health care needs

 

Nurse Line Services

Pacific Health Alliance Nurse Line is part of the Care Counseling Service.  The Nurse Line is available to members 24 hours per day, 365 days a year.  Members have access to Care Advisors to help them with symptoms or answer health related questions.  Our advisors have an average of 18 years clinical experience and services are available in English, Spanish and other languages upon request.

Our nurses help members:

  • Become better-informed healthcare consumers
  • Understand their specific diagnosis and condition(s)
  • Gain confidence when speaking with providers during office visits
  • Manage chronic illnesses and diseases daily
  • Avoid unnecessary emergency room visits
  • Become more educated on self-care for non-urgent injuries and illnesses

 

PHA Pre-Authorization Program

PHA Pre-Authorization Program is the process of determining the medical necessity of requested medical services.  The PHA Care Coordinators and Medical Directors work in partnership with medical providers to ensure each patient receives the appropriate in the appropriate setting for their medical condition.

Features of the PHA Pre-Authorization Program:

  • Use of Interqual evidence- based clinical decision making support system
  • Medical Directors are all active physicians licensed in California
  • Review for medically unnecessary care
  • Rapid turnaround time
  • Case management available
  • Inpatient and Outpatient review
  • Identification of high cost cases and third party liability
  • Electronic Interface with claims payors
  • Detailed reporting for re-insurance carriers

 

PHA Emergency Room Avoidance Program

Pacific Health Alliance works with you and your members to reduce the amount of unnecessary emergency room visits.  It is estimated that over $38 billion is wasted each year on these unnecessary visits.  Reducing this trend represents a significant opportunity to not only improve quality but also lower costs of healthcare.

What Pacific Health Alliance does to solve this problem:

  • Identify frequent Emergency Room users through a thorough examination of claims history
  • Encourages the use of our 24 hour Nurse Line which has been proven to decrease inappropriate emergency room use
  • Educates members through a variety of strategies of when and what level of service to choose
  • Provides all members access to resources designed to familiarize them with alternatives
  • Continued high-utilizers are contacted by a registered nurse to determine if additional resources are needed

 

PHA Safe at Home Program

The Pacific Health Alliance Safe at Home Program provides discharged patients with the resources necessary to ensure continued progression toward recovery and decreases the likelihood of an avoidable readmission.

The Safe at Home Program provides:

  • Engagement of the patient and/or caregiver at discharge
  • Development of single source contact for patient
  • Active case management
  • Ensure follow-up appointment scheduling and transportation
  • Establishment of proper contact with patient during 30 day period following a hospital discharge

 

To learn how Pacific Health Alliance cost-containment programs can help you achieve optimal healthcare, please contact our client services department at 1-800-533-4742.