Care Management

  • Care Management ranges from coordinating care for members with complex medical conditions to assistance with hospital discharge planning.

    Our philosophy is simple: We won't sacrifice quality nor deny our members benefit-eligible treatment. We also ensure that members receive care in the most appropriate setting.

    Accreditation: Premera is accredited by the National Committee for Quality Assurance (NCQA®). Achieving NCQA accreditation indicates that an organization is well managed and delivers high quality care and service. Accreditation enables Premera to communicate our vision of being the standard of excellence in our region, helping us to provide peace of mind to our members about their healthcare coverage.

    NCQA is a registered trademark of the National Committee for Quality Assurance.

  • Admission Screening and Triage

    Hospitals routinely notify Premera of all inpatient admissions, which allows us to verify benefits, link members to other programs and assess the need for case management. Care Management programs are completely voluntary. 

    Clinical Review

    Pre-authorization for most services is not required, but some may be reviewed for medical necessity. These include experimental or investigational procedures. Others are listed in the member benefit booklet as contract limitations or exclusions.

    • Before a service in the Practitioner Clinical Review Guideline is provided, a member or doctor is encouraged to contact us and request a Benefit Advisory. A Benefit Advisory is not a requirement nor is it a guarantee of payment. A Benefit Advisory is a review to determine if a service meets medical necessity criteria and if the member's plan has this type of benefit available.
    • After a service has been provided and billed, we review the list of the services in the Practitioner Clinical Review Guideline. Retrospective Reviews include but are not limited to determination of medical necessity, benefit clarification, appropriate application of benefits, pricing and coding questions, appeals and utilization patterns. A Retrospective Review may be conducted before the payment or as a post-payment audit.

    Care Compass

    Consumers are responsible for more of their healthcare decision-making than ever before. Healthcare decisions are the most difficult, challenging and stressful issues for families to deal with. The burden and stress placed on the consumer to manage their way through the complexities of today's complex healthcare system are significant.

    Care Compass provides expertise in assisting members navigate through the healthcare system. Plus, through an assessment process, we recommend programs and services for members who may be at early risk for health concerns. We also assist members in coordinating support services needed to assist in their recovery and ongoing care.

    Currently, the Care Compass program offers:

    • Preadmission Screening - RN Care Navigators are available to offer members education and pre-planning activities prior to undergoing surgery or procedures. Through education, members and their families' needs are determined and a plan is discussed to optimize the individual's health needs through their event and recovery.
    • Discharge Planning - RN Care Navigators work with the inpatient facilities to identify members who have had a serious illness or injury that may result in a period of time post-discharge that requires intensive follow up care. Together, the facilities and Care Compass nurses team up to plan for and coordinate care needs for the member when they are ready to leave the hospital.
    • Readmission Prevention - Care Navigators follows member's care upon discharge for moderately intense to intense health events that require short-term coordination of homecare, IV, rehabilitation or other related services. The goal of readmission prevention is to optimize recovery and facilitate education of the member and family during this health related event. If the member's recovery becomes longer term, the member is transferred to our complex case management team who coordinates further recovery and health improvement at a higher intensity level. The Care Navigator continues to make follow up calls to members until they feel that they no longer need the support.

    The Care Navigator is a Registered Nurse or healthcare trained professional. The Care Navigator is someone on “your side” to facilitate your healthcare needs and encourage health improvement. Our Care Navigators are available to support members in these ways to assist in coordinating acute, elective health-related events. 

    Case Management works cooperatively with our members and their physicians to identify and plan for the help they need to meet their healthcare condition. The goal? Better health outcomes and reduced readmissions. 

    • Complex Case Management:
      This voluntary service is offered to members with complex, catastrophic or unusually costly medical conditions. People facing these circumstances often find that working with multiple doctors and insurance benefits can be daunting. A Premera case manager (a nurse or social worker) serves as a single point of contact - and often a critical bridge to:
      • Ensure that members receive the right care, in the right place, at the right time through collaboration with providers, physicians and the member
      • Provide peace of mind for our members by helping them through the overwhelming healthcare system and maximize available benefits
      • Identifies alternate sources of funding and services
      • Reach out to members to make sure they are following their doctors discharge plans and identify complications early to prevent readmission
      • Serves as a liaison with Medical Group clinical staff

    Current Case Management Programs

    Breast and Lung Cancer Program
    The Breast and Lung Cancer program is designed to help members learn about their diagnosis and treatment plan, and to help them get the most out of their health plan's benefits. Program services are provided by Premera.

    An experienced nurse is assigned to each participant to help throughout their treatment. The nurse can:

    • Answer questions about treatment options and healthcare benefits
    • Help locate community resources
    • Provide early identification of treatment side effects
    • Suggest strategies to pursue during treatment
    • Provide support and encouragement for members and their families
    • Facilitate communications about claims and benefits with customer service

    To learn more about cancer or how to manage breast or lung cancer please see: