One of the first things your private insurance company will do when you report a catastrophic situation such as a spinal cord injury is assign you a case manager. This person will play a huge role in the rehabilitation process. If for some reason your insurance company does not offer this service, ask that one be assigned to you immediately.
Case managers help you navigate through the insurance maze, serving as a liaison between the policy holder and the insurance company. They are licensed professionals, usually registered nurses or masters-level vocational rehabilitation specialists. Both state and federal laws govern the practice of case management.
A telephonic case manager (caseload approximates 200) is a registered nurse who monitors patient care and paper flow from her office. He or she preauthorizes treatment, operating within your benefit plan and maintaining telephone contact with you monthly.
A personal or individualized case manager, whose caseload can be from 25-40 persons, is assigned within your geographic area, assuming a more active role. Although he or she makes sure you receive the most efficient and effective care for your illness, they cannot decide about coverage; instead, they direct benefit questions to your claims adjuster.
It is suggested that when your physician first suggests a test or treatment, get a brief description in writing and fax a copy to your case manager. The sooner this information is received, the more accurate the allocation of insurance coverage will be.
Your insurance booklet contains a precertification telephone number; call and ask for a supervisor. Tell them you are in need of immediate medical treatment and want some help navigating through the insurance system. Request that a case manager be assigned to you. You can never initiate this process too early.
Some questions to immediately ask your case manager include, "Who do you work for?" "What is the purpose of your role?" "Can I call you at any time with questions?" Because your case manager can become either your adversary or your ally, treat them like an ally; you will be more likely to get your needs met!