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, also known as Utilization Management, activities help our members get the right care at the right time and in the right setting. Our purpose is to help members receive appropriate care and make referrals to teams within Premera that can help coordinate care for complex conditions. Our program promotes applying clinical evidence-based guidelines to improve the appropriate use of services. Our goal is to help members to reduce harm from the use of unnecessary medical services and in doing so to make healthcare more affordable for all.
Clinical services that require prospective review/prior authorization/pre-service, inpatient services and retrospective review include medical and behavioral health, ancillary and alternative care and treatments, and specific drugs and therapies.
Admission notification: Inpatient admission notification simply informs a health plan that a patient has been admitted. It is required for all acute care hospital admissions and discharges. Inpatient admission notification is not a substitute for prior authorization. Some services require prior authorization in addition to admission notification, e.g. planned/elective admission.
Admission request: Different than admission notification, this is a request for authorization of an admission. Provider or facility must submit admission request to Clinical Review if they consider inpatient admission necessary and would like to request authorization.
Benefit level exception (BLE): This is a pre-service request that an out-of-network provider be paid at the in-network level.
Clinical Review by Code (CRC) List: Each procedure code is listed with coverage status and requirement for prior authorization and medical necessity review.
Concurrent Review: ongoing inpatient review. Inpatient clinicians perform case reviews using evidence-based guidelines and following NCQA standards.
Inpatient Review: Initial review of an admission request, focusing on delivery of appropriate inpatient care at the right time and place. Inpatient clinicians perform case reviews using evidence-based guidelines and following NCQA standards.
Planned/elective admission: These services require prior authorization and admission notification. Use the Clinical Review by Code List to check if the service requires prior authorization.
Pre-service review: A provider can request a pre-service review before they provide services or treatment to members. There is not a penalty, but Premera will hold the claim and ask for medical records.
Prospective Review: Initial review for prior authorization of outpatient requests before the service is rendered or prior to an inpatient admission. Providers must submit clinical notes supporting the medical necessity of the request.
Prior Authorization (PA) review: provider must request prior authorization for many services before they take place. Not getting prior authorization beforehand can result in a payment penalty for provider and member.
Retrospective Review (post service): This is a claim review for services that have already been rendered. This review occurs before payment.
Unplanned admission: Not scheduled or related to elective procedures, these admissions primarily originate in emergency departments.
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 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:
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 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.
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:
Prior Authorization/Pre-Service Review/Prospective Review
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.
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 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.
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.
Facilities and hospitals are required to notify us of all admissions in order for claims to be reimbursed without delay. These services are:
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.
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).
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 formularies are designed to address rising pharmacy costs, ensure access to the highest value medications and keep healthcare affordable for everyone. Regarding generic utilization:
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:
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).
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.
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:
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:
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's purpose is to improve members' lives by making healthcare work better. We are focused on improving the health of, and increasing the value to, our members by driving positive change in the healthcare space. To achieve this, we focus on solving the four biggest problems for members of cost, appropriateness, underuse, and experience.
Solving these problems requires innovation and a structured approach. We use data and analytics to build programs that lead to lower cost, better care, and improved member experience. We align our resources and structure to operate as efficiently as possible and always remain open to new ideas that will solve our members’ four biggest problems. We constantly scan the market for innovations developed outside of our walls and work to implement these when they are better than our own. We believe in breaking down barriers and moving through innovation to implementation with intensive monitoring to ensure programs achieve objectives.
In addition, Premera focuses on the Institute for Healthcare Improvement (IHI) Triple Aim goals of:
Premera views quality standards as a starting point. We conduct uniform quality assessments through consistent national measures aligned with industry-recognized standards and market-specific measures that address local care gaps. Key areas addressed include:
The purpose of Premera’s Quality Program is to measure how effectively we are achieving the Premera purpose and highlighting where to focus our efforts. Quality Program initiatives are designed to improve organizational effectiveness and support the Premera Purpose, the Strategic Imperatives, and the Health Care Services Strategic Plan.
Healthcare quality is primarily focused on providing the right care, to the right individual, at the right time, and in the right place.
The goals of the Quality Program are to assure that Premera:
Our Quality Program empowers members and providers in a comprehensive and meaningful way. The Quality Program creates and administers member engagement initiatives that empower members to be active participants in their healthcare. We partner with our providers and the healthcare delivery system to support members' empowerment. We do this by regularly delivering patient-specific information on opportunities for care, clinical best practices, and member feedback to providers.
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 members which improve the health, safety, cost, simplicity, and ease our members’ experience.
The corporate Quality Program covers Premera’s commercial plans, including FEP, state Exchange plans of Premera Blue Cross, LifeWise of Washington, and Premera Blue Cross Blue Shield of Alaska. Quality Programs, projects, and initiatives may address all markets or focus on a particular population, product, process, or member 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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