Premera has adopted the United States Preventive Services Task Force (USPSTF) Guide to Clinical Preventive Services. 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, in addition to content from other recognized sources, have been selected and formatted in two quick reference guides for provider use. These resources are available below.
Preventive Health – Guide to Clinical Preventive Services for Adults
Preventive Health – Guide to Clinical Preventive Services for Children/Adolescents
HEDIS is a set of nationally recognized performance measures developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS is used by over 90% of US health plans to measure quality of care, access to care, and satisfaction with care.
If screenings are done in your office, documenting and coding these thoroughly helps assess quality care for HEDIS measurements and allows us to assess appropriate programs to assist members with health conditions. The more accurate claims are coded, the less medical record reviews are needed for HEDIS measurements. Please view our new coding tip sheet to ensure you are sending complete claims and are paid for all the services you provide.
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. Premera adopts evidence-based national guidelines for treatment of conditions addressed by Premera disease management, quality and pharmacy programs. Performance on key guidelines is measured and analyzed annually.
Premera’s adoption of the following guidelines does not guarantee benefit coverage for services and is not an authorization of payment for specific procedures. Members’ benefits can be verified online at premera.com/provider.
Guidelines are reviewed and approved for adoption at least every two years by Premera’s Clinical Quality Improvement Committee. The committee’s composition reflects a variety of medical and behavioral health specialties, as well as geographic regions served by Premera.
ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents
American Academy of Pediatrics (AAP)
Diagnosis and Management of Asthma
Institute for Clinical Systems Improvement (ICSI)
AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2011 Update
American Heart Association, American College of Cardiology
2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women - 2011 Update: A Guideline from the American Heart Association
American Heart Association
Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease
American College of Physicians (ACP), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), European Respiratory Society (ERS)
Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease
Global Initiative for Chronic Obstructive Lung Disease (GOLD)
Practice Guideline for the Treatment of Patients with Major Depressive Disorder
American Psychiatric Association (APA)
Adult Depression in Primary Care
Standards of Medical Care in Diabetes – 2014
American Diabetes Association (ADA)
Guiding Principles for the Care of People with or at Risk for Diabetes
U.S. Department of Health and Human Services (HHS), National Diabetes Education Program (NDEP)
2013 ACCF/AHA Guideline for the Management of Heart Failure
American College of Cardiology Foundation (ACCF), American Heart Association (AHA)
Clinical Practice Guidelines in Oncology
American Society of Clinical Oncology (ASCO)
National Comprehensive Cancer Network (NCCN)
Additional guideline resources are available at the National Guideline Clearinghouse at: www.guideline.gov. Premera reviews and updates clinical practice guidelines at least every two years.
Premera recognizes the challenges physicians may encounter when treating patients who have chronic, non-cancer pain and are taking controlled substances for pain management. Below are links to various resources and tools for providers to use in managing these patients’ care.
Washington State Department of health
Provider/Patient Pain Management Agreement: