Kev xa mus thiab kev tso cai

Cov kws kho mob ED tuaj yeem xa ncaj qha mus rau cov kws kho mob tshwj xeeb hauv qab no rau cov kev kho mob uas tsis tau tso cai ua ntej:

• Orthopedic kws phais: rau cov ntaub ntawv los yog xav tias qhov tseeb, sprains thiab hom.
• General kws phais: rau mob cholecystitis.
• Ophthalmologists: rau thaum muaj xwm ceev retinal detachment; corneal abrasions, hlawv thiab khaws cia txawv teb chaws lub cev; mob ocular kab mob; thiab glaucoma xwm ceev.
• Kev tswj qhov mob: rau mob hnyav lossis mob hnyav ntawm lub lumbar ntev thiab / lossis ncauj tsev menyuam radiculopathy.

Lub Alliance muab cov kev pabcuam Complex Case Management rau cov tswv cuab uas muaj qee yam mob ntev, kev kuaj mob hnyav thiab lwm yam teeb meem kho mob nyuaj. Yog xav paub ntxiv, saib lub Nplooj Case.

Alliance Care Coordination cov kev pab cuam pab cov tswv cuab uas tsis tshua muaj kev xav tau, tsis yog kev kho mob xws li cov khoom siv kho mob ntev thiab kev thauj mus los. Saib cov Nplooj ntawv saib xyuas kev sib koom tes rau ib daim ntawv teev tag nrho.

Siv cov Case Management daim ntawv xa mus xa ib tug tswv cuab mus rau cov kev pab cuam Complex Care lossis Care Coordination. Koj tuaj yeem xa daim foos hauv online lossis fax mus rau Alliance.

Tus neeg muab kev pabcuam yog lub luag haujlwm kom tau txais kev pom zoo Alliance ua ntej muab qee yam kev pabcuam.

Txhawm rau thov kev tso cai, ua kom tiav ib qho Daim Ntawv Thov Kev Tso Cai (AR). thiab xa nws los ntawm:

• Lub Alliance Tus kws kho mob Portal.
• Fax rau 831-430-5850.
• Xa ntawv mus rau: Central California Alliance for Health, PO Box 660015, Scotts Valley, CA 95067-0012.

Cov kev pabcuam uas xav tau kev tso cai ua ntej suav nrog, tab sis tsis txwv rau:

• Kev kho tsis haum.
• Kev kho mob dermatology.
• Kev Pabcuam Hauv Tsev.
• MRI thiab CT scans tsis muaj npe.
• Kev kho lub cev, ua haujlwm thiab hais lus.
• Qee qhov kev kho mob podiatric
• Kev phais mob sab nraud tsis tshwm sim.
• Tag nrho cov implants.
• Txhua lub tsev kho mob uas tsis yog xwm txheej ceev.
• Cov khoom siv kho mob thiab DME.
• Txhua qhov kev thov rau kev xa mus rau sab nraud, cov chaw muab kev pabcuam thiab cov chaw tsis muaj ntawv cog lus.
• Kev xa mus rau cov kev pabcuam uas yuav tsum tau muab rau sab nraud ntawm thaj chaw pabcuam Alliance, rau txhua tus tswvcuab tshwj tsis yog Medi-Cal cov tswvcuab.
• Thov xa mus rau WCM CCS-cov tswv cuab tsim nyog.
• Thov kev pab tu thiab kev thauj mus los rau WCM CCS-cov tswv cuab tsim nyog.
• Cov tshuaj uas tsis yog nyob rau hauv Alliance Drug Formulary los yog tshaj qhov txwv ntawm hnub, hnub nyoog, ntau npaum li cas los yog tus nqi tso cai rau ib tug formulary. Kev kho mob khoom noj khoom haus kho mob thiab khoom noj khoom haus enteral xav tau kev tso cai ua ntej. Thov xa mus rau Kev Pabcuam Pharmacy kom paub ntau ntxiv txog kev xa cov ntawv tso cai ua ntej rau cov tshuaj.

Yog xav paub ntxiv, saib cov Phau ntawv muab kev pab thiab cov Kev Tso Cai Thov Txheej Txheem Txoj Cai.

Alliance's Utilization Management (UM) qhov kev pab cuam siv cov txheej txheem ua tiav, kev sib koom ua ke uas nquag:

• Ntsuam xyuas thiab tswj kev siv cov kev pab kho mob xa mus rau peb cov tswv cuab.
• Kev tshawb nrhiav pom cov cib fim rau kev txhim kho.

Qhov kev pab cuam UM xyuas kom meej tias:

• Cov tswv cuab tau txais qhov tsim nyog kom muaj nuj nqis thiab cov kev pab kho mob zoo.
• Kev pabcuam raug xa tuaj raws sijhawm.

Qhov kev pab cuam UM txheeb xyuas qhov sib npaug rau kev saib xyuas kev noj qab haus huv uas tsim nyog, muaj txiaj ntsig zoo rau txhua tus tswv cuab. Rau lub hom phiaj kev tso cai, ib qho kev thov lossis cov khoom siv kho mob tau pom zoo yog tias nws yog cov txiaj ntsig tau txais kev pab thiab txiav txim siab tias yuav tsum tau kho mob.

UM qhov kev pab cuam muab cov txheej txheem txhim khu kev qha los tshuaj xyuas, saib xyuas, tshuaj xyuas thiab daws cov teeb meem ntsig txog kev siv hluav taws xob nrog rau kev pom zoo thiab siv cov kev cuam tshuam los txhim kho kev siv thiab kev faib cov peev txheej.

Txhawm rau ua tiav cov kev txiav txim siab tsim nyog thiab tsim nyog, UM cov txheej txheem thov siv qhov systematic, zoo ib yam ntawm kev siv cov txheej txheem tswj kev siv. Kev txiav txim siab kho mob yog txiav txim siab los ntawm Alliance cov neeg tsim nyog, paub txog UM pab neeg siv cov ntaub ntawv pov thawj-raws li cov lus qhia tsim thiab pom zoo los ntawm Alliance's Utilization Management Committee (UMC). Rau kev txiav txim siab xav tau kev kho mob, Alliance siv cov ntaub ntawv pov thawj raws li kev xav tau kev kho mob hauv kev txiav txim siab hierarchy.

Cov ntawv luam ntawm Alliance Utilization Management txoj cai tuaj yeem saib hauv Alliance Txoj Cai hauv qab no.

Kev txiav txim siab Hierarchy

1. Medi-Cal Cov Lus Qhia Txog Kev Kho Mob (thaum muaj).
2. Cov txheej txheem ua pov thawj, xws li:
   • MCG cov txheej txheem saib xyuas.
   • Medicare (CMS) Cov Lus Qhia.
3. Title 22 California Codes of Regulation Division 5 cov qauv.
4. Alliance Health Services thiab Pharmacy cov lus qhia, cov cai thiab cov txheej txheem
   pom zoo los ntawm UMC.
5. Cov lus pom zoo thiab teb chaws lees paub cov qauv kev coj ua.
6. Cov lus qhia tsim los ntawm lwm cov phiaj xwm kev noj qab haus huv.
7. Cov kws tshaj lij kev xav:
   • Cov kws pab tswv yim kho mob ua haujlwm rau pawg Alliance.
   • Kev tshuaj xyuas kev kho mob sab nraud.
8. Rau WCM CCS-cov tswv cuab tsim nyog:
   • Siv tag nrho cov txheej txheem CCS tam sim no thiab siv tau, suav nrog CCS cov cai tswjfwm, CCS tus lej lej, thiab CCS cov ntaub ntawv qhia txog kev pabcuam hauv kev tsim cov txheej txheem rau kev siv los ntawm tus thawj saib xyuas kev noj qab haus huv lossis tus sib npaug thiab lwm tus neeg ua haujlwm tswj xyuas kev saib xyuas rau tus tswvcuab CCS-kev tsim nyog.
   • Nyob rau hauv rooj plaub uas tsis muaj cov txheej txheem kho mob CCS, siv cov ntaub ntawv pov thawj los yog cov txheej txheem kho mob uas tsim nyog rau tus tswv cuab CCS-kev tsim nyog.

Lwm Cov Kev Pab Ntxiv

• Pawg Neeg Tawm Tswv Yim rau Kev Txhaj Tshuaj Tiv Thaiv Kab Mob (ACIP) Cov Lus Pom Zoo
• American Academy of Pediatrics Clinical Practice Guidelines Summary
• American College of Radiology Appropriateness Criteria
• American Diabetes Association
• Center for Disease Control (CDC) thiab Kev Tiv Thaiv
• Johns Hopkins Tshuaj Tshawb Fawb
• Mayo Clinical Resources
• National Comprehensive Cancer Network: Hais Txog Cov Kev Qhia Txog Kev Kho Mob
• American Board of Medical Specialties (ABMS)
• National Heart Lung and Blood Institute: US Clinical Practice Guidelines Summaries  
• Teb Chaws Asmeskas Tiv Thaiv Kev Pabcuam Task Force
• Wheeless' Phau ntawv ntawm Orthopedics
• UpToDate: Cov ntaub ntawv pov thawj-raws li kev txiav txim siab kho mob
• National Institute for Health thiab Care Excellence (NICE)
• New England Journal of Medicine (NEJM)
• Kab Mob & Cov Mob: Medscape Reference
• NEJM Journal Watch
• Txog MEDLINE thiab PubMed: Phau Ntawv Qhia Txog Kev Pabcuam
• Chaw rau Medicare & Medicaid Services (CMS)

Tsab ntawv kho mob lossis tsab ntawv kws muag tshuaj kuj yuav yog ib qho kev pab ntxiv.

• 404-1101 Txuas A Utilization Management Program Doc Review pom zoo
• 404-1101 Utilization Management Program
• 404-1102 Inpatient Review
• 404-1103 Kev tshem tawm plaub hau
• 404-1108 Kev Saib Xyuas Kev Tshaj Tawm / Hauv Kev Siv Cov Kev Pabcuam
• 404-1109 Kev Tshaj Tawm Txog Kev Tswj Xyuas Kev Siv Siv rau cov neeg muab kev pab, cov tswv cuab, thiab cov pej xeem
• 404-1110 Pawg Neeg Saib Xyuas Kev Siv Siv Lub Luag Haujlwm thiab Kev Ua Haujlwm
• 404-1111 Kev Ntsuam Xyuas Kev Tswj Xyuas Kev Siv
• 404-1112 Kev Xav Tau Kho Mob- Lub Ntsiab Lus thiab Kev Thov Kev Pab Kho Mob rau Kev Thov Kev Tso Cai
• 404-1113 External Independent Medical Review
• 404-1114 Txuas A Matrix Continuity of Care Reqs
• 404-1114 Kev Saib Xyuas Txuas Ntxiv
• 404-1115 Terminal Mob
• 404-1201 Daim Ntawv Thov Kev Tso Cai
• 404-1202 Tom Qab Sijhawm Muaj Kev Npaj lossis Tus Kws Kho Mob Daim Ntawv Cog Lus
• 404-1203 Kev Kho Mob ntawm Varicose Veins
• 404-1204 Laparoscopy Cholecystectomy Tso Cai Txheej Txheem
• 404-1303 Xa mus rau Kev Sib Tham Thov Txheej Txheem
• 404-1305 Kev tshuaj ntsuam xyuas thiab xa mus rau Medically Eligible Children to California Children's Services (CCS) Program
• 404-1306 Extended (Sawv) Kev Tso Cai Xa Mus
• 404-1307 Kev Kho Mob Thib Ob Kev Xav
• 404-1309 Tus Tswv Cuab Nkag Mus Rau Cov Kev Pab Qhia Tus Kheej
• 404-1310 Txuas A Yuav Tsum Tau xa cov tswv cuab mus rau Tshwj xeeb P
• 404-1310 Cov Txheej Txheem Kev Tso Cai rau Kev xa mus rau sab nraud thiab tsis yog-Contrac
• 404-1312 Kev xa mus rau Cov Kws Kho Mob HIV/AIDS
• 404-1313 Lub luag haujlwm ntawm Tus Saib Xyuas Kev Pabcuam Tseem Ceeb suav nrog Kev Tswj Xyuas Tus Kheej thiab Kev Txhawb Nqa Tus Neeg Mob Hauv Tsev Kho Mob
• 404-1314 Cov me nyuam uas muaj Kev Kho Mob Tshwj Xeeb (CSHCN)
• 404-1316 Early Intervention Services
• 404-1401 Sterilization Consent Protocol
• 404-1520 Cov Txheej Txheem Hnub Ua Haujlwm
• 404-1521 Tsev Kho Mob Nyob Qhov Tshab Tawm, Tuag lossis Hloov Pauv tshwm sim rau hnub nkag
• 404-1523 Post-partum Hospital Stays
• 404-1524 Kev Saib Xyuas Lub Sij Hawm Ntev rau Medi-Cal Cov Tswv Cuab
• 404-1525 Attachment A Skilled Nursing Facility Levels of Care Matrix
• 404-1525 Txoj Cai Pabcuam Saib Xyuas Neeg Mob Txawj Ntse rau Medi-Cal
• 404-1526 Kev Pabcuam Tsev Khomob lossis Lub Chaw Pabcuam Saib Xyuas Neeg Mob Txawj Ntse rau Cov Tswvcuab Kev Tsis Txaus Siab rau Cov Tswvcuab
• 404-1527 Palliative Care
• 404-1528 Adult Complex Case Management
• 404-1529 Post Discharge Meal Delivery Program Benefits
• 404-1530 Pediatric Complex Case Management
• 404-1601 Txuas A DME Tso Cai Matrix Muab Kev Pab
• 404-1601 Cov Khoom Siv Kho Mob Ntev (DME) Tso Cai
• 404-1603 Kev Tso Cai Khoom Siv Kho Mob
• 404-1605 Cov Lus Qhia Tso Cai Rau Lub Rooj Zaum
• 404-1609 Negative Pressure Wound Therapy Pumps
• 404-1611 Transcutaneous Electrical Nerve Stimulation (TENS) Unit Tso Cai Ntsuam Xyuas Txheej Txheem
• 404-1612 BiPAP thiab CPAP Chav Tso Cai Txheej Txheem
• 404-1613 Rooj Tog Lift Chairs Tso Cai Thov Kev Tshawb Fawb
• 404-1614 High Frequency Chest Wall Oscillation Devices (Vest) Tso Cai
• 404-1615 Nebulizers
• 404-1617 Foot Orthotic and Prosthetic Appliances Guidelines
• 404-1618 Compression Garments
• 404-1702 Kev Pabcuam Family Planning Services rau Cov Tswvcuab
• 404-1703 Alliance Cov Tswv Cuab nrog cov txiaj ntsig qub tub rog
• 404-1704 Txuas Kev Kho Mob Rau Kev Kho Hniav Kho Hniav
• 404-1704 Attachment_B_PA_TAR_Reimbursement Scenarios
• 404-1704 Dental Anesthesia rau Alliance Medi-Cal Cov Tswv Cuab
• 404-1705 Kev Pab Kho Hniav rau Medi-Cal Cov Tswv Cuab
• 404-1706 Cov Lus Qhia Txog Kev Kho Mob Lub Cev
• 404-1707 Cov Kev Pab Cuam Tshuam rau Medi-Cal Cov Tswv Cuab
• 404-1708 Chiropractic Services
• 404-1709 Kev Kho Mob rau Knox Keene Kab Kev Lag Luam
• 404-1710 Pediatric Therapies rau Medi-Cal Recipients
• 404-1711 Pw Study (Polysomnopraphy/Sleep Disorder Testing) Tso Cai
• 404-1712 Biofeedback Training rau Urinary Incontinence
• 404-1713 Electromyography, Nerve Conduction Studies
• 404-1714 Kev Ntsuam Xyuas Technology
• 404-1715 Kev Ntsuas Kab Mob
• 404-1716 Epidermal Nerve Fiber Density Studies
• 404-1719 Tsev Kho Mob
• 404-1720 Phase II Kev Kho Mob Kho Mob
• 404-1720 Private Duty Nursing EPSDT Nyiaj Pab
• 404-1721 Antepartum Fetal Surveillance
• 404-1723 Kev Tso Cai Hloov Lub Cev Loj Loj
• 404-1724 Tsev Kho Mob Tsheb thauj mus los ntawm PCP Office
• 404-1725 Kev Thauj Mus Los Tsis Kho Mob
• 404-1726 Kev Thauj Mus Los Tsis Muaj Xwm Ceev
• 404-1727 Kev Pabcuam Telehealth rau Alliance Cov Tswvcuab
• 404-1728 Contraceptive Products and Services
• 404-1729 Pulmonary Rehabilitation Services
• 404-1730 Kev Kho Mob Khoom Noj Khoom Haus
• 404-1731 Tshuaj Pab Kho Mob
• 404-1732 Kev Saib Xyuas thiab Kev Thauj Mus Los rau Cov Tswv Cuab nrog CCS Kev Tsim Nyog
• 404-1733 Tag Nrho Hloov Hloov
• 404-1734 Allergy Immunotherapy
• 404-1734 Txuas A: Immunotherapy Tso Cai Thov Daim Ntawv Thov
• 404-1735 Long-Term External Cardiac Event Monitoring
• 404-1736 Kev soj ntsuam cov piam thaj tas li
• 404-1737 Panniculectomy & Lwm Lipectomy
• 404-1738 Community Health Worker Services
• 404-1739 Doula Services
• 404-1743 Intermediate Care Facility/Developmental Disabled Homes
• 404-1744 Txoj Cai Tswjfwm
• 404-1745 Lub Zej Zog Txhawb Txoj Cai rau Cov Khoom Noj Kho Mob
• 404-1746 Lub Zej Zog Txhawb Txoj Cai rau Kev Tso Nyiaj Hauv Tsev
• 404-1747 Lub Zej Zog Txhawb Txoj Cai rau Kev Hloov Pauv Hloov Pauv Kev Pabcuam