Care Management ranges from coordinating care for members with complex medical conditions to assistance with hospital discharge planning.
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 Friday, 7 a.m. to 7 p.m., PST, and Saturdays, 10 a.m. to 1 p.m. You can also email us at case.management@premera.com
For Individual Plan members, call customer service at 800-607-0546.
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
Prior authorization review can be required or recommended. To check the status of a code against a member's plan, sign in to Availity and use the prior authorization tool. You can submit the review and check its status online. The lists in the prior authorization tool are not exhaustive and do not include advanced imaging codes. The presence of codes on the list does not necessarily indicate coverage under the member benefits contract. Always use the prior authorization tool, consult the member benefit booklet, or contact a customer service representative to determine coverage for a specific medical service or supply.
If you have a change to a previously submitted prior authorization, call Care Management for instructions. A change or update to a service or procedure needs to be reviewed by a clinician. Learn more about prior authorization.
Healthier outcomes for moms and babies
BestBeginnings Maternity
Premera's maternity program, BestBeginnings, provides maternity and newborn programs for eligible members:
- Best Beginnings Maternity Program: Provides education and support services to pregnant members through the BestBeginnings mobile app and case management services for those eligible members identified as high-risk.
- Special Care for Baby: Provides case management on site or by phone, and assists facility staff in providing discharge planning, support, and resources for parents. It also includes concurrent review for neonatal intensive care unit (NICU) services.
Discharge support services
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.
Premera’s Discharge
Support Services provide expertise in assisting members through the healthcare
journey from transition from home to hospital and hospital to home.
Our licensed clinical staff provides the following services:
Pre-admission Member Outreach: Our licensed clinicians help prepare the member for a positive transition, even before the member has been admitted to the facility by:
- 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 support to address member needs such as ensuring caregiver support, transportation, and home safety issues are addressed.
Collaborative Discharge Planning: Our clinical staff works with members and providers to remove barriers to safe and timely discharge.
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. Our case managers follow the member's care upon discharge for health events that require short-term coordination of homecare, IV, rehabilitation or other related services. Our case managers work with the members to address their clinical and non-clinical barriers (i.e., social determinants of health) to health improvement and help members learn new behaviors to self-manage their conditions.
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.