Oversight Case Management is committed to provide assistance in all areas of cost containment and medical necessity review. Efforts include:

• establishment of a cooperative, professional relationship with case managers and utilization review vendors of our TPA clients

• assistance to our TPA and AU claims departments with research and review of experimental procedures and drugs, medical necessity issues, medical reviews and associated claims cost projections

• willingness and readiness to respond to medical questions

• assistance to our TPAs with discounting in the absence of a PPO and appropriate referral to tertiary or specialty networks

In order to be effective, Alliance Underwriters encourages our TPAs and their chosen UR/LCM vendors to be compliant with our notification procedures and cooperate with OCM efforts. At a minimum, plan documents should include UR pre-certification requirements for inpatient confinements.

As stated in our OCM Agreement, UR companies must provide weekly open case listings/OCLs to the OCM department listing all precertifications for the week for inpatient stays. Report data should include the patient's name and date of birth, the insured's social security number, the ICD-9 code and text diagnosis, the date of admission, dates of any procedures, the date of discharge (if it has occurred), the facility name and phone number, and the PPO. Hospitalized individuals should be included in the OCL until discharged. The UR company should obtain and report pathology results of all biopsies taken related to the detection of cancer.

The Large Case Management (LCM) company must send current copies of all case management reports to the AU OCM and provide continuing status reports on ongoing cases.

The TPA must provide advance notice to the AU Claims and/or OCM department at the earliest indication of a trigger diagnosis or one of the following conditions. It is essential that all available information be reported.

• complications of pregnancy
• cerebral vascular accidents (i.e. stroke)
• spinal cord injuries
• paralysis
• severe burns
• prolonged hospital stays for diabetic conditions
• organ transplants
• hospital stays of seven days or more
• survived cardiac or respiratory arrest

• premature births
• major head trauma
• amputations
• loss of eyesight or hearing
• multiple fractures
• AIDS, AIDS Related Complex, or disorders of the immune system
• coronary bypass
• malignancy of solid organ(s), blood, or lymphatic system

The list of "trigger diagnoses" includes those that have been identified by the medical community and by the insurance industry as any which can result in the need for extensive and/or expensive medical or surgical services.

The TPA must provide notification to the AU Claims and/or OCM department for any claimant with a trigger diagnosis immediately upon notification from the UR/LCM vendor; receipt of a request for benefit verification from a provider; presentation of a claim for payment; or receipt of a telephone call or written correspondence referencing a potentially catastrophic claim.

ALTERNATIVE CARE PROVISIONS (CASE MANAGEMENT)

The Alternative Care provision of a Plan allows case management flexibility in coordinating cost effective and medically necessary care, not otherwise covered under the Plan. In order for the Alternative Care provision to be used as intended, the TPA should require a written cost analysis of the proposed treatment from the LCM prior to allowing benefits on these claims.

Alternative Care must be reviewed and pre-approved by our Oversight Case Management to be considered for reinsurance benefits.

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