| Learn more about |
Description
of information |
| Case
Management |
Regence Case Managers, who are experienced registered nurses and social workers, provide one-on-one support and guidance for members facing complex or catastrophic health conditions. |
| Dental Care Management and Retrospective Review |
We apply appropriate Dental Care Management procedures and conduct retrospective data reviews. |
| Disease
Management |
Regence Disease Management programs offer both early intervention
and long-term management of chronic conditions, such as diabetes, cardiac
and respiratory conditions. |
| Integrated Care
Management (ICM) |
Our ICM program provides specialized, targeted attention and support to patients with complex health issues. ICM combines the core functionality of Regence Case Management, Regence Disease Management, Special Beginnings® and Health Coach into a single blended program, designed to better support the health needs of your patients. |
| Member
Programs |
Regence offers 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. |
Practice
Guidelines |
Regence supports the use of nationally recognized practice
guidelines to assist in determinations of the clinical appropriateness
of treatment services for medical and behavioral health. |
| 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,
level of care assessment and appropriate treatment setting.
| Not medically necessary
services and supplies |
| • |
Charges for services
and supplies determined to be not medically necessary by
Regence are a participating provider write-off. |
| • |
The provider may only bill members
for such services or supplies if the appropriate written member
consent been obtained. |
| |
|
| Investigational services
and supplies |
| • |
Charges for investigational
services and supplies are denied as member responsibility
for services delivered on or after January 1, 2010. Regence
encourages members to verify benefit coverage for proposed
services. |
| • |
Written
member consent acknowledging financial responsibility
is not required for services deemed investigational. However,
Regence encourages the provider to notify the member before
these services are rendered that the member may be financially
responsible for the charges. |
| • |
View services and supplies currently
considered investigational on the Regence
Customized and Significant Clinical Edits list. |
|
Pharmacy
Prior Authorization |
Pharmacy prior authorization information and forms
are located on the RegenceRx® Web site. |
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. |
| Radiology QI/American Imaging Management® (AIM®) |
Our Radiology Quality Initiative (RQI) is designed to support the use of advanced diagnostic imaging services based on widely accepted clinical judgment. We have partnered with AIM to administer the program. |
| Regence Rare Disease Condition Management Program |
Our Rare Disease Condition Management Program is an intensified care management program for our members with rare and complex conditions. |
