Integrated Health Management

Referrals to or questions about our Personal Health Support Services can be made by calling 888-742-1479 Monday - Friday 8 a.m. to 7 p.m. PST. You may fax the following information to 877-468-7377.

• Patient name
• Premera ID number and suffix
• Telephone number and contact name if contact is not the customer
• Reason for the referral

Care Transition Management interventions are designed to support patients during the transitions from home to hospital and hospital to home through:

• Preadmission patient outreach to patients undergoing targeted elective procedures to verify understanding of preadmission orders and post-discharge support at home
• Facility outreach to provide assistance for a safe and timely discharge
• Care coordination between multiple providers and levels of care
• Post-discharge patient outreach to identify barriers to optimal recovery, promote treatment adherence, and encourage recommended follow-up care

A corporate Medical Policy Committee composed of licensed physicians and nurses meets regularly to adopt and update all policies. Policies are reviewed and updated annually or more frequently if new relevant studies are published.

The following sources of information are used in developing and updating medical policies:

• BCBSA Medical Policy reference manual
• American Society of Addiction Medicine (ASAM) guidelines
• Noridian Administrative Services for durable medical equipment, prosthetics, orthotics, and supplies
• Carelon Medical Benefits Management clinical appropriate guidelines
• Change Healthcare InterQual
• EviCore Healthcare Clinical guidelines
• BCBSA Evidence Positioning System
• Hayes, Inc. (Knowledge Center and Technology Assessment Services)
• UpToDate
• National Comprehensive Cancer Network guidelines
• Published, credible scientific evidence in peer-reviewed medical literature

Independent external advisory groups:

• Practicing physician input
• Independent Review Organization materials

Our polices are also informed by practicing physicians who participate in our Pharmacy and Therapeutics Committee, our regional physician advisory committees, and contracted local practitioners. All policies are published on our external website.

We notify contracted physicians and providers of any medical policy change at least 90 days prior to the start date of the policy. This notification generally takes place through publication on the news section of our provider website. Visit the provider website to sign up for regular email notifications of policy changes and other Premera news. We occasionally mail notifications to provider offices.

When there are differences between the member's contract and medical policy, the member's contract prevails. The existence of a medical policy regarding a specific service or treatment does not guarantee that the member's contract covers that service.

Medical necessity

Medical necessity is a term used in health plan contracts to describe services that will be covered. The following definition is used in most of our contracts: those covered services and supplies that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that meet all of the following criterion:

• In accordance with generally accepted standards of medical practice**
• Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease
• Not primarily for the convenience of the patient, physician, or other healthcare provider
• Not more costly than alternative services or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease

** For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors

Experimental/Investigational services

This term is used in healthcare coverage plan contracts to describe which services are likely to be excluded from coverage. Most of our contracts use the following language: Experimental and/or investigational services may include a treatment, procedure, equipment, drug, drug usage, medical device or supply which meets one or more of the following criteria as determined by Premera:

Experimental or investigational services include a treatment, procedure, equipment, drug, drug usage, medical device or supply that meets one or more of the following criteria:

• A drug or device that can’t be lawfully marketed without the approval of the U.S. Food and Drug Administration, and hasn’t been granted such approval on the date the service is provided
• The service is subject to oversight by an Institutional Review Board
• No reliable evidence demonstrates that the service is effective, in clinical diagnosis, evaluation, management or treatment of the condition
• The service is the subject of ongoing clinical trials to determine its maximum tolerated dose, toxicity, safety or efficacy.
• Evaluation of reliable evidence indicates that additional research is necessary before the service can be classified as equally or more effective than conventional therapies

Reliable evidence includes but is not limited to reports and articles published in authoritative peer reviewed medical and scientific literature, and assessments and coverage recommendations published by the Blue Cross Blue Shield Association Evidence Positioning System.

The fact that services were furnished, prescribed, or approved by a physician or other qualified practitioner does not in and of itself mean that the covered services were medically necessary.

Distribution of Medical Necessity Criteria to Physicians and Providers

Physician and nurse reviewers at Premera apply a variety of criteria to assist in the determination of medical necessity. The following medical necessity criteria are available to contracted physicians and providers upon request:

• Company Medical Policy
• Change Healthcare InterQual
• American Society of Addiction Medicine (ASAM) Guidelines for Chemical Dependency

A contracted physician or provider can request specific criteria related to a medical decision for his/her patient. To request a copy of the criteria, contact the Care Management department at 7004 220th ST SW, MS 438 Mountlake Terrace, WA 98043. Copies of individual medical policies are available on our website or by email: medicalpolicy@premera.com.

Physician-to-Plan Physician Conversations (Peer to Peer)

Coverage decisions are based on standards of care and medical necessity. 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 within five days of the decision to ensure timely discussion.

Requestors must provide the name of the member, member ID, and specific services that were denied. Our Medical Services 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. This discussion does not represent an appeal.

Utilization Management Disclosures

All requests for coverage of services that do not appear to meet medical necessity criteria are reviewed initially by a clinician (nurse or behavioral health specialist). If the service does not meet medical necessity criteria, or if it is considered experimental/investigational, the case is referred to a Premera physician for review. A physician is the final arbitrator of any denials based on medical necessity or experimental/investigational status.

Ensuring Appropriate Service and Coverage

We are committed to covering our members' care and encourage appropriate use of healthcare services. Physicians, providers and Premera staff who make utilization-related decisions must comply with the following policy statement:

• Utilization management decisions are based on appropriateness of care and services, and existence of coverage.
• We do not compensate physicians, providers or other individuals conducting utilization review for denials of coverage or services.
• We do not provide financial incentives for utilization management decision-makers to encourage denials of coverage or services.

Providers can significantly improve claims payment timeliness by following the Prospective Review recommendations available at premera.com/provider (under Utilization Review). Simply enter the date of service and procedure code to determine if a medical necessity review is recommended.

Admission notification: Notification that a member has been admitted to a facility. Admission notification requirements vary. See Admission Notification for more details. Inpatient admission notification is not a substitute for prior authorization. Some services require prior authorization in addition to admission notification.

Benefit level exception (BLE): An exception made to allow in-network benefits for services provided at an out-of-network facility or by an out-of-network provider. The member is still subject to balance billing. BLEs must be requested before care is provided.

Clinical Review by Code (CRC) List: Each procedure code is listed with coverage status and requirement for prior authorization and medical necessity review.

Medical necessity criteria: Criteria developed to determine if services or care are safe, effective, and aligned with generally accepted standards of medical practice. See Medical Review Criteria above for more information.

Prior authorization: A plan requirement that services or care are authorized and determined to be medically necessary before they take place. Not all plans or services require prior authorization. Plans that don't require prior authorization will have medical necessity review done retrospectively. 

Review for medical necessity: Clinical utilization review for services or care that have medical necessity criteria and require review according to plan benefits. Medical necessity review may be prospective/preservice, concurrent, or retrospective.

Our confidentiality policy protects the confidentiality and privacy of our members' protected personal and medical information by preventing the unauthorized use and disclosure of such information by our associates and business associates.

Protected Personal Information

We are committed to maintaining the confidentiality of individuals' protected personal health and financial information (collectively referred to as “protected personal information” or PPI). We collect, use, and disclose PPI solely for routine business functions as required or permitted by law or regulation. We strictly prohibit the unauthorized disclosure of PPI by our associates and business associates, unless we have first obtained the member's written authorization.

We know standards of confidentiality are intrinsic to your role as a healthcare professional. As a contracted physician or provider, you are required to maintain the confidentiality of all PPI concerning any current or former patients (our members). In addition, you are also bound to observe certain state and federal privacy laws. At a minimum, each clinic should have each staff member sign a confidentiality statement upon employment in which the employee acknowledges the importance of maintaining the confidentiality of PPI. This is a Premera office site standard used in our credentialing and recredentialing process.

PPI is defined as any and all information created or received by the company that identifies or can readily be associated with the identity of an individual, whether oral or recorded in any form or medium, that directly relates to the:

• Past, present, or future physical, mental or behavioral health or condition of an individual
• Past, present, or future payment for the provision of healthcare to an individual
• Past, present, or future finances of an individual, including, without limitation, an individual's name, address, telephone number, Social Security Number, subscriber number or wage information.

Routine business function

Any activity undertaken by the company, or by a business associate on behalf of the company, for healthcare operations and payment activities, including, but not limited to:

• Carrying out the management functions of the company, including, but not limited to, underwriting, actuarial, care management, case management and quality reviews
• Obtaining subscription charges or
• Determining or fulfilling its responsibility for coverage under the health plan and for the provision of benefits under the health plan, including, but not limited to, member benefit eligibility, payment of member claims, customer service, and coordination of member benefits.

We expect all participating providers to comply by submitting medical records when we request. We may request medical records to complete a request for services for many reasons, not limited to these examples:

• Prior authorization (submit the records along with your review request).
• A provider or member appeals the decision and more information is needed to support the request.
• A claim is rebilled with different diagnosis/procedure code (e.g., CPT, HCPCS, ICD-9) or date-of-service.
• Quality reviews – described below

Visit our website prior authorization page, tools section and forms section to find more information on submitting medical records in different circumstances.

Quality review

The terms of the Practitioner Agreement address cooperation with health plan requests for copies of medical records needed to evaluate quality of care or in response to other quality auditing activities. When we request this type of data, we routinely notify medical offices five to 10 business days prior to the review. Practitioner reimbursement is not provided for patient records requested for quality purposes.

For Utilization Management reviews, when we request copies of a member's medical record, reimbursement is 25 cents per page, and only for those records specified in the request letter. We do not reimburse for records sent beyond the scope of the request letter.

Review for Medical Necessity

The company lists services, procedures, and devices that are reviewed for medical necessity. Depending on the customer contract, these services may result in customer or provider liability if the service is not pre-approved. All of the services will be reviewed post-service if a pre-service review was not done. Services found to be not medically necessary may not be covered. View the list of services in our code list.

Medical director/Physician oversight

A clinician (nurse or behavioral health specialist) initially reviews requests for coverage of services that require prior authorization. If the service cannot be approved per the criteria, or if it is considered experimental/investigational, the clinician refers the case to a physician for review. All denials based on clinical criteria are reviewed and issued by a physician.

Ensuring Appropriate Service and Coverage

We are committed to covering our customers' care and encourage appropriate use of healthcare services. Physicians, providers, and our staff who make utilization-related decisions must comply with the following policy statements:

• Utilization management decisions are based on appropriateness of care and services, and existence of coverage
• We do not compensate physicians, providers, or other individuals conducting utilization review for denials of coverage or services
• We do not provide financial incentives for utilization management decision-makers to encourage denials of coverage or services.

Review processes

Prior Authorization

Prior authorization is a contractual requirement for a provider to obtain approval in advance of certain services and has been required in many of our customer contracts. For customers with a plan subject to prior authorization, this prospective review will be required to determine medical necessity and coverage for inpatient services and various outpatient services, supplies, and drugs. Failure to obtain a prior authorization may result in financial penalty for the provider, customer, or both parties.

Resources and tools

The code list has codes that require prior authorization or pre-service review. You can also use our code check tool in Availity to confirm if a code requires prior authorization or pre-service review.

Providers located in Washington and Alaska can use our online prior authorization tool to submit medical records as part of supporting documentation.

View information for providers outside of Washington and Alaska.

Benefit level exception

If a medically necessary service cannot be performed within the member’s provide network, then an out-of-network service may be covered at the member’s in network benefit depending on the member’s contract provisions. A benefit level exception (BLE) to request that a service be paid at in-network level for an out-of-network provider must be requested prior to the service. If the request meets the defined exception criteria, the out-of-network service will be reimbursed at the customer’s in-network benefit. The member is still subject to balance billing. BLEs must be requested before care is provided.

Facilities and hospitals are required to notify us of all admissions in order for claims to be reimbursed without delay. These services are:

• Inpatient facility for acute care (planned/elective or unplanned admission)
• Inpatient facility (mental health and chemical dependency)
• Skilled Nursing Facility and acute rehabilitation admissions
• Residential Treatment Center

All planned or unplanned hospital admissions, including admitting through emergency department, must submit notifications to Clinical Review Department within one business day of the admission. Notification allows us to verify benefits, link customers to other programs, and assess the need for medical necessity review of the inpatient admission and referral to case management.

• Notify us of urgent/emergent admissions within 48 hours of the admission.
• Admission notification isn’t required for maternity delivery admissions, regardless of the length of the hospital stay (per the 48/96 rule*). No correspondence is generated for maternity-related stays.
• Other elective/scheduled admissions should complete the admission notification process prior to admission date.

Inpatient admission notification meets the admission notification requirement. However, this does not guarantee that services will be authorized or covered. All requests for medical necessity review and authorization must be accompanied by clinical records. To initiated request for a medical necessity determination, a request must be submitted with one of our Admission Notification forms.

We use evidence-based guidelines when reviewing concurrent cases and will assist facility on discharge planning accordingly based on evidence-based standard delivery of care. They may need to contact the attending physician or specialist for additional information about the case and care decision. Contracted physicians are expected to provide pertinent clinical information in response to these requests (see your contract for more information). Our evidence-based guidelines are developed from research science and/or national clinical criteria (such as InterQual).

Retrospective Review

We will review claims for services that are potentially cosmetic, experimental or investigational, not medically necessary, or have benefit limitations. This review occurs before payment. Obtaining pre-service reviews for medical necessity will result in faster claims payment and prevent unexpected retrospective denials. We strongly advise pre-service review for all items listed on the Clinical Codes Review List.

Retrospective review results in review of claims for benefit determination and/or medical necessity after receipt of a claim and prior to making a payment decision. All potential denials are based on medical necessity, correct assignment of benefit, or the use of experimental/investigative services/procedures that are reviewed by a medical director.

Delegated functions

We may delegate part of the clinical review functions to qualifying entities. This does not include delegation of benefit quotes, technology assessment, benefit exceptions, customer/provider satisfaction with the health plan, over- and under-utilization of services, or pharmacy benefit management. Visit our website to see a complete, current list of our delegated functions.

Pre-service requests

Fax pre-service request form to 800-843-1114

Actual payment is subject to our payment policies, the subscriber's benefits, and eligibility at the time of service, and the application of certain industry standard claims adjudication procedures. Confirm eligibility and benefits information on our website, or contact Customer Service to determine if your patient's plan has this requirement.

The Premera formularies are designed to address rising pharmacy costs, ensure access to the highest value medications and keep healthcare affordable for everyone. Regarding generic utilization:

• More than 85 percent of all brand medications are now available as generics.
• The average Premera customer can save up to $453 a year by using generic medications instead of brand medications.
• Customers save money with a generic prescription because these drugs are available at the lowest copay through the customer’s health plan.
• When a generic equivalent is not available, there may be a generic in the same class of drugs that is a good alternative.
• • Premera’s formularies are developed by an independent Pharmacy & Therapeutics Committee made up of practicing providers recognized in their fields across Washington and Alaska to ensure evidence-based, clinically appropriate medication management decisions are made.

Our pharmacy prior authorization program focuses pharmaceutical care for selected customer contracts. This program promotes appropriate utilization of specific drugs. Point of sale edits occur at the pharmacy if our medical necessity guidelines are not meet. Our Pharmacy and Therapeutics Committee approves these edits, and the criteria development is based on one or more of the following resources:

• National clinical practice guidelines
• Blue Cross Blue Shield Association (BCBSA) evidence-based guidelines
• Premera medical policy
• A reputable clinical source including drug package inserts, peer-reviewed journal articles, and clinical trials
• Accepted treatment standards based on our clinical pathways and/or medical and pharmacy best practices

We utilize electronic Prior Authorization to help streamline medical necessity reviews for providers & members though platforms such as Cover My Meds. If a prescription does not meet the Premera clinical criteria, the computer system alerts the dispensing pharmacist. The prescription will not be filled until it has been reviewed with either the Electronic Prior Authorization submission or Prior Authorization fax-back forms, which are available at premera.com/pharmacy.

Our Specialty Pharmacy Program helps customers manage specialty drugs. Specialty drugs are high-cost drugs, often self-injected or self-administered and used to treat complex or rare conditions including multiple sclerosis, rheumatoid arthritis, and hepatitis C. Our specialty pharmacy vendors are Accredo (for all groups) and AllianceRx Walgreens Prime (for select groups).

Our Specialty Pharmacy Program helps members manage specialty drugs. Specialty drugs are high-cost drugs, often self-injected or self-administered and used to treat complex or rare conditions including multiple sclerosis, rheumatoid arthritis, and hepatitis C. Our specialty pharmacy vendors are Accredo (for all plans) and AllianceRx Walgreens Prime (for select plans).

Specialty pharmacies focus on the delivery and clinical management of specialty drugs. They are staffed by pharmacists, nurses, and patient care representatives who are trained to meet the unique needs of people taking specialty drugs. Besides dispensing the prescriptions and arranging for delivery of the specialty drugs, they also provide members with clinical services including drug and disease information, support, and counseling. In addition, there are multiple patient cost savings strategies in place with our specialty pharmacies that may reduce the cost burden on patients, depending on their plan. Our SaveOnSP program through Accredo helps connect patients to manufacturer patient assistance programs to ensure a patient maximizes their benefit and minimizes their out-of-pocket cost.

When administering a drug, providers may use their normal process to acquire a specialty drug for administration and bill us directly, or they may choose to use one of the Specialty Pharmacy partners to acquire a specialty drug for administration in the clinic. Using a specialty pharmacy may help reduce administrative and financial burden as well as inventory costs. The specialty pharmacies can deliver specialty drugs directly to the provider’s office, just in time for the patient’s clinic visit.

Member benefits may require the use of one of our contracted specialty pharmacies to fill specialty medications. View the Mandatory Specialty Drug List to see medications that are included in the Specialty Pharmacy Program. Prescriptions for these medications may be called in to Accredo Health Group 800-689-6592 or into Alliance Rx Walgreens Prime specialty pharmacy 877-223-6447.

Visit our provider website to read more about our Specialty Pharmacy Program.

Description

The RationalMed^® program was implemented in 2009 to help address the issues that may arise due to the fragmented healthcare system. These gaps in care occur due to patients seeing multiple providers, and the lack of knowledge or information sharing which can lead to underutilization, overutilization, or conflicts in care.

The program integrates medical and pharmacy claims data and applies a rules based engine based on nationally accepted scientific evidence to identify potential care opportunities. The ensuing alerts are sent to providers and pharmacists in order to improve health care quality. Providers are sent faxes, letters, and notifications via the electronic health record, depending on the urgency of the alerts and pharmacists are alerted at the point of sale.

Examples of RationalMed^® Alerts

Some examples of RationalMed® alerts include:

• A patient has a history of congenital heart defects and is prescribed a weight loss medication. Both the pharmacist and the prescribing provider will receive an alert that, due to this medical condition, the prescribed medication is contraindicated. By stopping or preventing the patient from taking the medication, we could have possibly prevented a hospitalization or ER visit related to this contraindication.
• A patient with diabetes and high blood pressure does not have any prescriptions for a particular blood pressure medication (ACE-I) that is recommended in all major national guidelines. Perhaps the doctor did write a prescription for that customer for the ACE-I but that customer did not ever fill the prescription. This allows the provider to have a discussion with the customer about the reasons why it is important to take the medication.

Premera has added to our digital member experience by introducing an outreach program to help patients identify opportunities to save on their prescriptions. Premera’s Pharmacy Care Alerts program launched in 2020 and sends members individualized and actionable information on how to lower their out-of-pocket drug costs with clinically appropriate, lower cost drug alternatives prior to their next prescription fill. Under this program, members are notified by text or e-mail of lower cost drug alternatives which, if used, will result in the member saving at least $100 dollars for the remainder of the plan year.

Members will be eligible if they meet the following criteria:

• Opted into receiving text messages from Premera
• Have a claim for a drug on the targeted drug list
• Member must be able to save at least $100 for the remainder of their plan year by switching to an alternative drug
• Must be the subscriber, their spouse or domestic partner

If a savings opportunity is available, the member will receive an alert prior to their next fill. Pharmacy savings alerts contain a link that takes the member to the log in page for their Premera.com account. After they log in, the member is steered to a page on Premera.com that shows the drug that triggered the alert, the lowest cost alternative, and details about both including cost and savings. The page shows the prescriber's information and asks the member to contact the prescriber about switching medications.

Premera is deeply committed to the Quintuple Aim, which focuses on improving health outcomes, enhancing patient experiences, reducing costs, ensuring provider satisfaction, and promoting health equity. This commitment is evident in our strategic initiatives and programs aimed at delivering high-quality, affordable care. Our approach to population health management is grounded in the principles of the Quintuple Aim, ensuring that every aspect of our operations aligns with these goals. By integrating managed care principles and implementing a proactive trend management system, Premera strives to enhance affordability and manage costs effectively.

Moreover, our dedication to the Quintuple Aim extends to Premera partnerships and collaborations across various departments. We work closely with providers to deliver the highest quality care for both providers and customers in Washington and Alaska. Our efforts in improving clinical quality, coding quality, and overall performance are driven by a vision to be a trusted clinical partner, facilitating high-quality care at the right place, right cost, and right time, every time. This holistic approach underscores our unwavering commitment to achieving the Quintuple Aim and ensuring the best possible outcomes for our members.

Our Quality Improvement model leads quality improvement at Premera through a combination of measurement, strategy, insights, and operations with the program’s management and governance as the foundation of our work.

The Quality Improvement model consists of measurement, insights, strategy, and operations supported by management and governance functions.

• Measurement
  • HEDIS®
  • CAHPS®
  • Other quality measures
• Insights
  • Performance management
  • Predictive analysis
  • Insights and recommendations
• Strategy
  • HEDIS® data strategy
  • Provider performance improvement
  • Member engagement and outreach
  • CAHPS® improvement
• Operations
  • HEDIS®
  • Provider engagement
  • Member engagement
  • CAHPS® member experience
• Quality program management and governance
  • NCQA accreditation
  • Regulatory requirements
  • Quality of care

Each year, the Quality program identifies priorities that align with our customers’ needs and in support of corporate strategies and goals. The program’s priorities encompass clinical quality performance improvement efforts as well as Quality program management needs.

Quality program leadership sets clinical quality performance improvement activities to align with quality and corporate strategies and identified needs.

Quality program leadership also identifies key priorities for overall Quality program management, including those for accreditation, regulatory reporting, and ongoing quality of care and governance.

• NCQA health plan accreditation – Commercial PPO, Commercial HMO, Individual EPO/PPO: Accredited status
• Regulatory reporting: Submitted and approved
  • Annual HEDIS and CAHPS® submissions
  • Individual Quality Improvement Summary (QIS) – Individual EPO/PPO
  • Other reports and data required by external agencies
• Quality of care
• Quality governance

Oversight of the Quality program is provided through a committee structure, which allows for the flow of information to and from the Premera Board of Directors. The board has delegated oversight to the Premera Quality Committee (PQC). The PQC oversees the Premera Quality Improvement Committee (PQIC), which has five quality-related committees reporting directly to it: Clinical Quality Improvement Committee (CQIC), Credentialing Committee-East/West (CCEW), Delegation Oversight Committee (DOC), Medical Management Oversight Committee (MMOC), and Service Quality Improvement Committee (SQIC).

Premera engages physicians and other health providers in Quality program activities and committees, in the review of care management issues relevant to their specialty, and in assisting Premera to eliminate wasteful activity and improve the quality and efficiency of shared processes. Network medical and behavioral health practitioners are involved in the Quality program when they:

• Agree to contract provisions regarding cooperation with quality improvement activities, confidentiality of member information and access to medical records
• Participate in provider quality improvement programs and activities
• Participate as members of physician advisory groups, utilization management workgroups and quality committees
• Provide input in the design of activities to improve member health and wellness, community health and the care, safety, and/or value of service provided to members
• Supply information needed for quality measurements and improvement projects
• Participate as decision-making members of the Pharmacy & Therapeutics Committee, and clinical criteria review processes

For questions about membership on Premera's quality committees, contact a Premera medical director.

Premera adopts clinical practice guidelines for the provision of non-preventive acute and chronic services relevant to its member population and for preventive and non-preventive behavioral health services. Evidence-based guidelines from recognized sources are designed to guide practitioner and member decisions about appropriate healthcare for specific clinical circumstances. Performance on key guidelines is measured and analyzed annually.

Premera's adoption of a national guideline or the inclusion of any statement made within a clinical practice guideline, does not guarantee benefit coverage for services and is not authorization of payment for specific procedures. Members' benefits can be verified online at premera.com/provider.

Clinical Practice Guidelines are available via links to national associations and guideline sources from our website at premera.com/provider.

Recommendation and approval

Guideline recommendations are made by network practitioners, the Pharmacy and Therapeutics Committee, the Utilization Management Committee, and medical directors representing Premera's clinical program activities.

Clinical practice guidelines are reviewed, updated as needed and approved by our Clinical Quality Improvement Committee. While the guidelines reflect national recommendations, they are not a substitute for the clinical judgment of practitioners advising and caring for individual patients.

Premera has adopted the United States Preventive Services Task Force (USPSTF) Guide to Clinical Preventive Services for Children and Adolescents, and Adults. The guideline is evidence-based, relying on current scientific studies.

Immunizations are part of USPSTF recommendations for Preventive Health Services, and Premera recommends the Centers for Disease Control & Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) for an up-to-date Immunization Schedule.

USPSTF “A” and “B” grade services with content from other recognized sources, have been selected and formatted in two quick reference guides for provider use: 1) Preventive Service guidelines for Children and Adolescents, and 2) Preventive Service guidelines for Adults. These resources are available to print or download from our provider website.

All USPSTF services rated as A or B are covered in full in accordance with federal health care reform or are covered at a reduced out-of-pocket cost for member’s who are enrolled in grandfathered plans. Verify benefits by checking our website or calling the Customer Service number listed on the back of the patient’s ID card.