| Case Management |
Regence Case Managers are experienced
registered nurses and social workers who will
provide one on one support and guidance for
any disease or health condition. |
| Clinical
Practice Guidelines |
Regence supports the use of nationally
recognized practice guidelines to assist in determinations
of the clinical appropriateness of treatment
services. |
| Disease Management |
Disease management programs
offer both early intervention and long-term
management of chronic conditions such as diabetes,
cardiac and respiratory conditions. Regence
currently offers two disease management programs:
|
| Medical 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
Regence’s commitment to ongoing quality
care for our members. We have developed standards
and performance goals and continue to monitor
them to identify improvement opportunities. |
| Special Beginnings® |
Our
Special Beginnings® prenatal
program is used to provide education and
support pregnant women, at any risk level,
to decrease the number of premature deliveries
and low birth weight infants. |
