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Care management
We provide a wide range of care management programs and resources designed to support our
members at any stage of health. These programs are either targeted to specific conditions or
designed to improve or maintain overall health. All programs are intended to supplement and
reinforce the care and guidance you provide to our members. Most feature clinical one-on-one
member support. Program availability may vary by group and benefit plan.
Peer-to-Peer review
A peer-to-peer review is a telephone discussion of a medical necessity denial between a
Regence medical director and a provider requesting authorization or coverage of a service
before the service is performed. This process is an opportunity to review the reason(s) for the
denial based on the applicable policy criteria. A peer-to-peer discussion is not
specialty-matched and will not often result in a reversal of the denial. The peer-to-peer must be
requested within 15 calendar days of the determination date and before an appeal has been
initiated. Contact our Provider Contact Center to see whether a peer-to-peer review may be
scheduled. The Provider Contact Center phone number is located in the Contact Us section of
our provider website. Learn more about our appeals process in the Appeals sections of our
Administrative Manual.
The following information and resources are offered to provide support to physicians,
other health care professionals and their staff.
Programs
Learn more about the following programs in the Medical Management section of our website
under Programs:
Case Management
The Regence case management program provides easy access to important one-on-one
patient support. Members facing a serious or sudden medical situation have a case manager
available to answer questions and provide information so that they can make informed decisions
based on their health care coverage options and focus on healing.
Case managers are experienced registered nurses and social workers. They work with
members and their providers to support the physician's treatment plan with development of a
care plan based on the patient's needs, social support system, benefits and physician input.
A case manager's role includes:
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Coordinating care and removing barriers to care
Contributing to the member's safety and quality of life
Achieving maximum value for the member's medical benefits
Developing care plans based on the member's unique situation
Acting as member advocate by providing expert advice and navigation
In this administrative manual, “Regence” refers to the following: Regence BlueShield of Idaho, Regence
BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah, and Regence BlueShield (in
select counties of Washington). When information does not apply to all these plans across the four states,
then this administrative manual will identify the plan(s) or state(s) to which that specific
information applies.
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Monitoring and assuring delivery of timely, medically appropriate and
effective interventions
Dental Care Management
We apply appropriate Dental Care Management procedures and conduct retrospective data
reviews to ensure that treatment provided:
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Is consistent with widely accepted standards of practice
Could not have been omitted without adversely affecting the patient’s condition or quality
of care
Is not primarily for the convenience of the patient, the participating dental provider or any
other person
Is the least costly appropriate treatment and location that can be used safely to treat the
patient’s condition
Is the appropriate type, level, amount and frequency of care necessary to treat a dental
condition or injury that is harmful to the health of a patient
Diabetes Management (Oregon only)
Under Oregon House Bill 2432, insurers are required to cover health services, medications and
supplies medically necessary for the management of diabetes during pregnancy through six
weeks postpartum without member cost-sharing. When a member is diagnosed with a
pregnancy and has diabetes (Type 1, 2 or gestational), we require you to complete and return a
Diabetes Management Form for the member. The form is located in our Library section under
Forms on our website
Disease Management
The Regence Disease Management program is available for our group and Individual members,
including Medicare Advantage. Note: Federal Employee Program® (FEP®) members who reside
in Oregon, Utah and Clark County, Washington participate in our Regence Disease
Management program. Disease management programs for FEP members in Idaho or
Washington (excluding Clark County, Washington) continue to be managed by Blue Cross of
Idaho or Premera Blue Cross.
Regence registered nurses and care advocate staff focus on helping members close gaps in
care related to one or more of the following conditions:
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Diabetes
Coronary artery disease (CAD)
Congestive heart failure (CHF)
Asthma – Administrative Services Only (ASO) and FEP members only
Chronic obstructive pulmonary disease (COPD) – ASO and FEP members only
We identify members who are eligible for the program and invite them to enroll. Providers can
also refer members to participate in the program.
In this administrative manual, “Regence” refers to the following: Regence BlueShield of Idaho, Regence
BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah, and Regence BlueShield (in
select counties of Washington). When information does not apply to all these plans across the four states,
then this administrative manual will identify the plan(s) or state(s) to which that specific
information applies.
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Members enrolled in Regence Disease Management will receive:
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Clinical support
Educational materials
Twice yearly newsletters
Help with making the most of office visits
Long-term management of chronic conditions
Early intervention when gaps in care are identified
Assistance with understanding and following provider care recommendations
Education about the patient's condition so the member will better understand the care
plan providers have recommended
Other outreach, as needed, based on unique individual needs
Regence Condition Manager, our disease management program coordinated by our vendor,
Optum, will continue for ASO.
Member programs
We offer a variety of programs as enhancements to the total benefit package provided to our
members. These programs help our members live healthier lives and reinforce and support
treatment plans with their provider.
Advanced Imaging Navigator (Oregon and Washington only [except Asotin and
Garfield counties])
The Advanced Imaging Navigator program is administered through AIM Specialty
HealthSM (AIM). As part of the program, AIM provides proactive outreach to Oregon- and
Washington-based members by phone, contacting members to alert them of overall
health care cost savings opportunities for diagnostic Computed Tomography (CT),
Magnetic Resonance (MRI/MRA) services that require an order number through AIM.
All providers who perform the advanced diagnostic imaging services noted above should
submit a completed assessment for each modality that they offer using AIM’s OptiNet
online assessment tool as this information is used when AIM provides outreach to the
member. The assessment tool is available on AIM’s website at
aimspecialtyhealth.com/goweb.
Health Coach
This program provides one-on-one support for your patients to set and reach goals for a
healthier lifestyle.
Regence Advantages
Discounts are offered to our members from a number of leading
health-related companies.
In this administrative manual, “Regence” refers to the following: Regence BlueShield of Idaho, Regence
BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah, and Regence BlueShield (in
select counties of Washington). When information does not apply to all these plans across the four states,
then this administrative manual will identify the plan(s) or state(s) to which that specific
information applies.
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Regence Advice24
Our 24/7 nurse advice line program, administered through Optum, offers members:
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Toll-free access to registered nurses utilizing:
o Appropriate care advice and follow-up as necessary
o Education about prescriptions, lifestyle choices and tests
o General health information, including care for minor injuries and illnesses
Online access to more than 700 videos
Regence BabyWise
The Regence BabyWise maternity management program provides the following:
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Newsletters
Prenatal education
Help finding resources
Individual needs assessment
Personal support to help achieve a healthy pregnancy and ultimately a healthy,
full-term baby
Verify if your patients are eligible for BabyWise by calling 1 (888) 569-2229.
FEP members have the Pregnancy Care Incentive program, providing education and
support for expectant mothers to achieve a safe and health pregnancy and delivery. FEP
members will have incentives available to them to support a healthy pregnancy in 2016.
Encourage them to talk to their maternity case manager to participate.
Physical Medicine program
This program is designed to meet our commitment to our members to ensure:
They obtain the most from their health care coverage
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We are being responsible stewards of the cost of health care
Treatments they receive are medically necessary and are at the right time and place to
improve their quality of life.
Our Utilization Management (UM) program requires compliance with the Physical Medicine
program. eviCore healthcare (eviCore) (formerly CareCore National, LLC) administers our
Physical Medicine program component of our overall UM program. Partnering with eviCore
allows us to provide quality support to both providers and members.
Our Physical Medicine program includes the following components:
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Spinal surgeries
Pain management and arthroscopy/joint replacement
Physical medicine and therapies (physical, occupational, speech and massage
therapies; acupuncture and chiropractic/manipulation treatments
In this administrative manual, “Regence” refers to the following: Regence BlueShield of Idaho, Regence
BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah, and Regence BlueShield (in
select counties of Washington). When information does not apply to all these plans across the four states,
then this administrative manual will identify the plan(s) or state(s) to which that specific
information applies.
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Quality Program
The Quality Program (QP) supports our commitment to ongoing quality care for our members.
We have developed standards and performance goals and continue to monitor them to identify
improvement opportunities.
Participation in Regence QP activities is required in our agreements with physicians, other
health care professionals and facilities.
Using provider data
Measuring and reporting health care quality is important. Affiliated network providers
acknowledge and agree that the plan may use the performance data collected for quality
improvement activities. Performance data collected includes, but is not limited to, member
experience, Healthcare Effectiveness Data and Information Set (HEDIS®) performance and
appointment access data that is used to implement quality initiatives to improve care and
service, as well as providing patients with information and tools to help them make informed
choices to pursue the best available care.
Radiology Quality Initiative (RQI)
Our Radiology Quality Initiative (RQI) promotes the use of advanced diagnostic imaging
services based on widely accepted clinical judgment. We have partnered with AIM Specialty
HealthSM (AIM) at aimspecialtyhealth.com to administer the program for specified members.
There are two components to RQI, our radiology benefit program. They include:
1. Ordering/referring non-radiological physicians, other health care professionals and/or
their trained staff must contact AIM to obtain an order number before scheduling an
elective outpatient diagnostic imaging procedure.
2. Advanced Imaging Authorization to review for medical necessity.
Referrals (Idaho, Oregon, Washington)
A referral must be in place in order for the specialty physician or other referral provider’s
services to be eligible for reimbursement, when a Medicare Advantage member requires
specialized treatment beyond the scope of the primary care provider (PCP).
The referral section outlines the following:
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Referral rules
Financial responsibility
Accessing referral reports
Referral submission process
Specialty provider information
Member referral dispute process
Exceptions to the referral requirements
In this administrative manual, “Regence” refers to the following: Regence BlueShield of Idaho, Regence
BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah, and Regence BlueShield (in
select counties of Washington). When information does not apply to all these plans across the four states,
then this administrative manual will identify the plan(s) or state(s) to which that specific
information applies.
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Personalized Care Support program
We are focused on supporting the health care needs of our members and their families at any
stage of life or illness. We also want to support providers in delivering quality care that honors
their patients' wishes for treatment. Our members’ benefits include palliative care services. In
addition, our members have access to specialized care management services.
Sleep Medicine program
Our Sleep Medicine program is designed to manage testing and therapy services for sleep
disorders. This program is administered by AIM. Physicians and other health care professionals
ordering services listed below must first contact AIM to request an order number prior to
services being rendered.
Services managed under this program include:
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Titration studies
Home sleep testing (HST)
Oral appliances for sleep therapy
In-lab sleep studies (Polysomnography [PSG])
Initial treatment orders (Automatic Positive Airway Pressure [APAP], Continuous Positive
Airway Pressure [CPAP], Bilevel Positive Airway Pressure [BPAP])
Ongoing treatment orders (APAP, CPAP, BPAP)
Pre-authorization
Learn more about the following pre-authorization programs in the Pre-authorization section of
our website:
Pre-authorization
Pre-authorization is a prospective determination performed by licensed health care
professionals. The intent is to determine the medical necessity and appropriateness of the
proposed treatment, a level of care assessment and the appropriate treatment setting.
Failure to secure approval for services subject to pre-authorization will result in claim
non-payment and provider write-off. Our members may not be balance billed.
Note: Charges for services and supplies that we determine to be not medically necessary are a
participating provider write-off.
Investigational services and supplies:
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Charges for investigational services and supplies are denied as member responsibility.
We encourage members to verify benefit coverage for proposed services.
Written member consent acknowledging financial responsibility is not required for
services deemed investigational. However, we encourage the provider to notify the
member before these services are rendered that the member may be financially
responsible for the charges. A sample written member consent form is located in the
Library section of our website under Forms.
In this administrative manual, “Regence” refers to the following: Regence BlueShield of Idaho, Regence
BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah, and Regence BlueShield (in
select counties of Washington). When information does not apply to all these plans across the four states,
then this administrative manual will identify the plan(s) or state(s) to which that specific
information applies.
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View services and supplies currently considered investigational on the Customized and
Significant Clinical Edits list located in the Claims and payment section of our website under
Coding Toolkit.
Pharmacy prior authorization
Pharmacy prior authorization information and forms are located on the OmedaRxTM website
at omedarx.com.
Polices
Learn more about our policies and guidelines in the Policies section in the Library on our
website. These include:
Clinical Position Statements
Clinical Position Statements contain Regence’s position on certain medical treatments, tests or
medications. The position summaries are based on research from scientific literature,
government approval status, and evidence-based treatment guidelines supporting clinical best
practices/standards of care. Although the services described in these position statements do not
have related policy criteria and are not subject to routine medical necessity review, utilization
related to these services may be subject to audit.
Clinical Practice Guidelines
We support the use of nationally recognized practice guidelines to assist in determinations of
the clinical appropriateness of treatment services for medical and behavioral health.
Medical, reimbursement, medication and dental policy
Our policies are used as guidelines for coverage determinations in all health care insurance
products, unless otherwise indicated. Benefit determinations are based on applicable member
contract language. Plan language will be followed if there are any conflicts between these
Policies and the Plan.
In this administrative manual, “Regence” refers to the following: Regence BlueShield of Idaho, Regence
BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah, and Regence BlueShield (in
select counties of Washington). When information does not apply to all these plans across the four states,
then this administrative manual will identify the plan(s) or state(s) to which that specific
information applies.
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