Our utilization management program promotes the delivery of appropriate, effective, and efficient care, including medical and pharmacy services and equipment. Here you can learn more about criteria availability, staff access, and our incentive statement.
Access to medical necessity utilization management
Physician and nurse reviewers at Premera use written criteria to assist in the determination of medical necessity. The following medical necessity criteria are used and available to contracted providers upon request:
- Company Medical Policy and Clinical Guidelines (on external website and updated at least annually)
- McKesson InterQual Clinical Criteria
- Carelon Medical Benefits Management Guidelines (radiology, cardiac, and radiation oncology)
- eviCore Healthcare Solutions (physical therapy, massage therapy, occupational therapy)
- American Society of Addiction Medicine Guidelines for Chemical Dependency
- Durable Medical Equipment Regional Carriers
Provider can request criteria related to a specific medical decision for a patient by calling Clinical Review at 877-342-5258, option 3, 8 a.m. – 5 p.m., Monday through Friday. View our complete medical policies and clinical practice guidelines.
Access to information about the utilization management process
Providers can contact clinical review staff at 877-342-5258, option 3, during regular business hours, Monday through Friday, 8 a.m. to 5 p.m., Pacific Standard Time, to discuss specific utilization management requirements and procedures or the utilization management process. If calling using a non-toll-free number, the call will be answered by a corporate operator and routed appropriately. Corporate operators are allowed to accept collect calls.
Ensuring appropriate service and coverage
We’re committed to covering our members’ care and encourage appropriate use of healthcare services. Providers and Premera staff who make utilization-related decisions must comply with the following policies:
- Utilization management decisions are based on appropriateness of care and services and existence of coverage.
- We don't compensate physicians, providers, or other individuals conducting utilization review for denials of coverage or services.
- We don't provide financial incentives for utilization management decision-makers to encourage decisions that result in under utilization.
Medical director calls (also called peer-to-peer)
Providers who receive an adverse decision (denial) related to clinical review for medical necessity or experimental/investigational status can discuss the decision with a physician reviewer. The request may be made by calling 877-835-5672. Often a same-day call back can be arranged.
Please keep in mind the following:
- This discussion does not represent an appeal.
- Requestors must provide the name of the member, member ID, and specific services that were denied.
- Our clinical review department will arrange for a conference call between the requesting provider and a plan medical director.
- The phone conversation will not necessarily be with a peer-matched specialty reviewer (specialty matched peer review is part of the Level I appeal process).