Premera’s Personal Health Support Services provide effective assistance for your patients who are experiencing health complexity resulting from acute or chronic medical or mental health conditions including, substance use disorders, inadequate social support, and/or limited or poorly coordinated access to healthcare services.
Our clinicians partner with patients, their caregivers, and providers to identify and eliminate clinical and non-clinical barriers to optimal health. Personal Health Support interventions support the provider-patient relationship, identify and facilitate removal of barriers to good self-management, and promote adherence to the prescribed treatment plan.
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 or by faxing the following information to 877-468-7377.
Care Transition Management interventions are designed to support patients during the transitions from home to hospital and hospital to home through:
Medical policies are developed to assist Premera staff in managing over, under, and inappropriate utilization of healthcare services, and to establish coverage for new and developing medical and behavior health procedures, devices, and pharmaceutical agents. We use these policies as guidelines to evaluate the medical necessity of particular service or treatment or to determine if they are investigational or experimental.
Medical policies are available on the provider website; select Medical Policies under Reference Info.
Many of our policies are adopted from policies approved by the Blue Cross Blue Shield Association's (BCBSA) Medical Policy Panel (MPP). The MPP is composed of medical directors representing Blue Cross and/or Blue Shield plans across the United States. We make our own determinations about whether to adopt the national medical policies and may make changes to represent regional variations in practice when appropriate. We also develop unique policies as needed.
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:
Independent external advisory groups:
Our polices are also informed by practicing physicians who participate in our Pharmacy and Therapeutics Committee, our Oncology Advisory Panel, 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 our 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.
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 Care Management.
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:
** 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
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:
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 Technical Evaluation Center (TEC).
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.
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:
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: firstname.lastname@example.org.
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 seven 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.
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.
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:
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.
Clinical Review activities support medical quality and encourage cost-conscious action through collaboration with Premera internal departments and external organizations. Clinical Review includes utilization review activities for prospective, concurrent, and retrospective review of inpatient and outpatient medical and behavioral healthcare and services, ancillary and alternative care and treatments, and pharmaceutical products and services.
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. See our section on Contact Information, Confidentiality, and Appointment Access for further information.
We request medical records for a variety of reasons:
Visit our website prior authorization page, tools section and forms section to find more information on submitting medical records in different circumstances.
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.
We list 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. The list of services, Clinical Review Codes, is available on the provider website under Utilization Review/Prospective Review.
A clinician (nurse or behavioral health specialist) initially reviews all requests for coverage of services that do not appear to meet medical necessity criteria. If the service does not meet medical necessity criteria, or if it's considered experimental/investigational, the clinician refers the case to one of our physicians for review. A physician is the final arbitrator of any denials based on medical necessity or experimental/investigational status.
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:
We do not provide financial incentives for utilization management decision-makers to encourage denials of coverage or services.
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.
Even in the absence of a prior authorization requirement, we recommend you request a prospective review for the procedures and services that we routinely review for medical necessity (e.g., considered cosmetic, experimental, or investigational, contract exclusions, or contract limitations).
The Clinical Review by Code List, is available on the provider website under Utilization Review. This document lists codes that require prior authorization or pre-service review.
You can also use our code check tool 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.
If you’re an out-of-area provider you can submit your prior authorization and supporting medical documentation by fax, and you’ll find the request form on our website.
Sometimes it is reasonable for a customer to receive services from a provider or facility not in his/her network. Depending on the customer’s contract provisions, out-of-network services may be covered at a lower rate or not at all. A benefit level exception is a request for services to be paid at in-network level for an out-of-network provider and must be requested prior to the service. If the request meets the defined exception criteria, we may allow out-of-network services to be reimbursed at the customer’s in-network benefit.
We ask hospitals to notify us of all inpatient admissions. For some contracts this may be required (prior authorization), therefore failure to notify and obtain approval may result in financial penalty for the customer, provider, or both parties. Notification allows us to verify benefits, link customers to other programs, and assess the need for case management.
Some plans may be subject to prior authorization. Please refer to back of customer ID card.
These types of admissions also require prior authorization. See the utilization review section of our provider website for more information.
Fax admission notification to 800-843-1114.
We use internal guidelines when reviewing cases. 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).
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 Review by Code 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.
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, pharmacy benefit management, or appeals. Visit our website to see a complete, current list of our delegated functions.
Our pharmacy programs promote choice, savings, and safety for our members. We focus on minimizing our members' out-of-pocket expenses, maximizing their safety when prescription drugs are required, and supporting your care recommendations for them.
The Premera generics program is designed to address rising pharmacy costs and keep healthcare affordable for everyone. Consider the following:
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:
If a prescription does not meet the Premera clinical criteria, the computer system alerts the pharmacist. The prescription will not be filled until it has been reviewed with the Prior Authorization Fax-back Form available at premera.com/pharmacy. Electronic Prior Authorization submission or Prior Authorization fax-back forms are available at premera.com/pharmacy.
Note: Drugs may be added or deleted from the prior authorization program at any time without prior notification.
ePocrates is an electronic drug information resource and health plan formulary guide. The software can be accessed a computer or smartphone. ePocrates offers the following benefits for physicians:
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 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. Additionally, they coordinate prior authorizations directly with us.
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.
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.
Some examples of RationalMed® alerts include:
The Quality Program works through and with the Premera organization, its providers, and purchasers. We work together to develop and deploy holistic, customer-centric quality improvement solutions that address the four customer problems of cost, necessary care, unnecessary care, and experience.
The goals of the Quality Program are to assure that Premera:
We want our customers to say, "You take great care of me and make it simple and easy." The Quality Program empowers Premera, providers, purchasers, and patients to fulfill our purpose. Our Quality Program addresses the four main customer problems of cost, appropriateness, underuse, and experience. Healthcare quality is primarily focused on providing the right care, to the right individual, at the right time, in the right place.
Our Quality Program empowers customers and providers in a comprehensive and meaningful way:
The Quality Program is responsible for the accreditation process for Premera and LifeWise products, as well as annually reporting quality metric data for ratings. Additionally, the program uses these indicators to develop and deploy programs for our customers which improve the health, safety, cost, simplicity, and ease our customers’ experience.
The corporate Quality Program covers Premera’s commercial plans. Quality Program projects and initiatives may address all markets or focus on a particular population, product, process, or customer group.
Collaborating with stakeholders and supported by a corporate program infrastructure, Premera works to achieve the following objectives through the Quality Program:
The scope of the corporate Quality Program includes:
Health plan performance monitoring and improvement encompasses key indicators of service quality and efficiency, clinical quality and outcomes, patient safety, complaints, access to care and service, customer and provider satisfaction, communication and decision support, and program effectiveness. Activities are planned and tracked using an annual quality work plan. The Quality Program is evaluated annually.
Practitioner and provider collaboration with the health plan's quality improvement program is essential. Individual practitioner and institutional provider contracts require that:
Subcommittees within Premera's Quality Program include practitioner representation. This enables participating practitioners to provide regional clinical expertise and input to Premera's Quality Program. These committees include:
Areas of quality oversight and governance include:
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.
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 from our website.
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.
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