• 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 will not sacrifice quality nor deny 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 signals 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 achieve our mission: To provide peace of mind to our members about their healthcare coverage.

    Care Management Programs

    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. Learn more about Admission Notification.

    Clinical Review

    Pre-service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit the review and check the status of the review online. These lists are not exhaustive and do not include advanced imaging codes. The presence of codes on this list does not necessarily indicate coverage under the member benefits contract, as member contracts differ in their benefits. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determine coverage for a specific medical service or supply.

    View services currently reviewed for medical necessity:

    If you have a change to a previously submitted prospective review, call Care Management for instructions. A change or update to a service or procedure needs to be reviewed by a clinician. Learn more about Prospective Review.

    AlereTM Women's & Children's Health for Maternity and Newborn Programs

    Premera is partnering with Alere Women's & Children's Health to bring Maternity and Newborn Programs to eligible members.

    • The Maternity Program (effective Sept. 1, 2013) provides education and support services to all eligible pregnant members and case management services for those eligible members identified as high-risk.
    • The Newborn Program (effective July 1, 2013) provides case management on site or by phone, and assists facility staff in providing discharge planning, support, and resources for parents. It will also include concurrent review for neonatal intensive care unit (NICU) services effective Aug. 1, 2013.

    Learn more about Alere services at Alere.com. Alere is a trademark of the Alere group of companies.

    Care Transition Management

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

    Care Transition Management provides expertise in assisting members through the healthcare system. Through an assessment process, we recommend programs and services for members who may be at early risk for health concerns. Our Care Transition Management program supports members during transition from home to hospital and hospital to home.

    Our licensed clinical staff provides the following services:

    Preadmission Member Outreach: One of our licensed clinicians helps prepare the member for a positive transition, even before the member has been admitted to the facility by:

    • Educating the member about their treatment plan
    • Assessing the needs of the member and their family or other key caregivers
    • Identifying potential barriers to care
    • Developing a plan for optimal post-discharge care.

    Collaborative Discharge Planning: Our clinical staff works with members and providers to coordinate safe discharge plans and post-discharge needs.

    Concurrent Review: Care Transition Managers ensure quality of care for members through concurrent review during a member’s inpatient stay. By monitoring medical necessity, our members receive appropriate care at the appropriate level, for the appropriate length of stay.

    Readmission Prevention: A clinician provides outreach to members within 72 hours of discharge notification to identify barriers to optimal recovery, promote treatment adherence and encourage recommended follow-up care. Care Transition Managers follow the member’s care upon discharge for health events that require short-term coordination of homecare, IV, rehabilitation or other related services. If the member’s recovery becomes longer term, the member is transferred to our complex case management team which coordinates further recovery and health improvement at a higher level.

    Integrated Case Management

    This voluntary service is offered to participants with health complexity, high utilization, and functional impairment. Health complexity encompasses multiple diagnoses, physical and mental health co-morbidities, personal, social, and financial upheaval, and health system issues. Integrated Case Management works cooperatively with members and physicians to identify and overcome clinical and non-clinical barriers to improve health outcomes.

    How to Refer Your Patients for Integrated Case Management Services 

    Providers can refer eligible Premera members to receive personal health support by calling 888-742-1479. The team is available to take referrals by phone and answer questions Monday through Thursday, 6 a.m. to 7 p.m., PST, and Fridays, 6 a.m. to 6 p.m. You can also email us at case.management@premera.com