Regence provides 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.
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. |
