Medical management

Our care management department provides support to members based on each individual’s risks and unmet needs. These care needs are assessed by licensed nurses, social workers and counselors, as well as non-clinical professionals. We use a bio-psycho-social model (BPS) to help us identify what care our members need. Then, the integrated care manager performs a health risk assessment to determine the member’s medical, behavioral health and bio-psychosocial status.

Care managers work with the member, member’s family, PCP, psychiatrist, substance abuse counselor or any other healthcare team member to achieve a quality-focused, cost-effective care plan. Care management educates members on their specific disease and how to prevent worsening of their illness or any complications. The goal is to maintain or improve their health status.

Care management programs include, but are not limited to:

  • Pregnancy outreach and high-risk OB
  • Special health care needs
  • Behavioral health/substance abuse

You may have concerns about one of your patients.  We can help coordinate many needed services. Just, call 1-855-242-0802 and ask for the case management department. You can refer your patients to Care Management.

Our chronic care management programs help members manage specific conditions. We assist with regular communications, targeted outreach and support, and focused education.

The conditions in our program include diabetes, asthma, heart failure, sickle cell anemia, hepatitis C, obesity and HIV/AIDS.

To learn more, just call 1-855-242-0802 and ask for the chronic care management department. You can refer your patients to Care Management.

Aetna Better Health of Louisiana maintains quality management (QM) through a Quality Assessment and Performance Improvement (QAPI) program. This involves multiple organizational components and committees.  The primary goal of the QM program is to improve the health status of members -- or maintain current health status when the member’s condition is not amenable to improvement.

Aetna Better Health of Louisiana’s QM program is a continuous quality improvement process that includes comprehensive quality assessment and performance improvement activities.  These activities continuously and proactively review our clinical and operational programs and processes to identify opportunities for improvement.  This enables us to:

  • Assess current practices in both clinical and non-clinical areas
  • Identify opportunities for improvement
  • Select the most effective interventions
  • Evaluate and measure the success of implemented interventions, refining the interventions as necessary

 We have created a Quality Management Oversight Committee (QMOC). Its primary purpose is to integrate quality management and performance improvement activities throughout the health plan and the provider network.  The committee provides executive oversight of the QAPI program and makes recommendations to the Board of Directors about Aetna Better Health of Louisiana’s quality management and performance improvement activities. The committee also works to make sure the QAPI program is integrated throughout the organization, and among departments, delegated organizations, and network providers.  Major functions of the QMOC Committee include:

  • Confirming that quality activities are designed to improve the quality of care and services provided to members
  • Reviewing and evaluating the results of quality improvement activities
  • Reviewing and approving studies, standards, clinical guidelines, trends in quality and utilization management indicators, and satisfaction surveys
  • Advising and making recommendations to improve the health plan

Reviewing and evaluating company-wide, performance-monitoring activities, including care management, customer service, credentialing, claims, grievance and appeals, prevention and wellness, provider services and quality and utilization management

Aetna develops QAPI objectives each year as outlined in our annual QAPI Program Description, which documents the scope, structure and function of the QAPI. We also evaluate our success in achieving our annual QAPI goals each year and document the results in our Quality Assessment and Improvement Program Evaluation.  The QAPI Program Description and our annual evaluation are available to you upon request.   Please call the Quality Department at 1-855-242-0802 for your free copy.

We are offering a program to help your patients manage their diabetes. Care4life is a diabetes education and support program with: 

  • Healthy recipes and nutrition tips
  • Reminders for medications and doctors’ appointments
  • Blood sugar tracking
  • Exercise and weight goals

They can use Care4life through an app on their phone, text messages and the Care4life website. When they sign up, they will get personalized content based on the information they choose to provide. They can also set reminders for things like medications, appointments and testing blood sugar. All this is available at no cost to your patient.

Care4life and the American Diabetes Association worked together on this program.

To sign up, they can download the Care4life app for iOS or Android or go to the website and use code: AETNALA. Care4life is available to them at no cost. However, depending on their cell phone plan, standard text message and data rates may apply.

If you have questions, please contact the Provider Services Department at 1-855-242-0802.

The completion of this Pregnancy Notification Form as early as possible allows us to best service our members to achieve a healthy pregnancy outcome. Please fill out this electronic form and submit so that it may directly reach our care management team in an expedited manner.

The completion of this form will help to identify high-risk pregnancies and assist in linking these members to case management enrollment. If you have any questions, please contact our Provider Services department at 1-855-242-0802.  

If you prefer to fax this form, you may fax to 1-866-776-2813, Attn: Case Management.

Louisiana Department of Health Breast Pump Coverage Health Plan Advisory

Electric Breast Pump Attestation and Instructions

Medline Breast Pump Ordering (English|Spanish)

Other Breast Pump Providers:

Southern Medical Adaptive Solutions, Inc.

McKesson Patient Care Solutions, Inc.

Innovative Orthotics & Prosthetics of Louisiana, Inc.

Byram Healthcare Centers

Aeroflow Healthcare