Regence provides a wide range of care management programs and resources designed
to support our members at any stage of health. Care management programs are
either targeted to specific conditions or designed to improve or maintain overall
health. All care management 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.
The following information and resources are offered to provide support to
physicians, other health care professionals and their staff:
| 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 |
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/AIM Specialty Health™ (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. |
