Services available through LifeWise Care Management programs help members navigate the healthcare system with a range of options available to:
Our prior authorization process includes a benefit review prior to the date the service is performed to confirm coverage, and to link members to appropriate Care Management programs.
Prior authorization is required in most member contracts for inpatient services and various outpatient services, supplies and drugs in order to determine medical necessity and benefits in place at the time of service. A medical necessity review occurs before services are rendered.
Prior authorization includes, but is not limited to:
Prior to obtaining a service or procedure listed in the Practitioner Clinical Review Guideline providers are encouraged to contact LifeWise and request a Benefit Advisory. A Benefit Advisory is not a requirement nor is it a guarantee of payment. A Benefit Advisory is a review of the service provided to determine if this service is covered under the benefit plan and if the service meets predetermined medical necessity criteria for the service.
If a pre-service review has not been requested for a service or procedure on the Practitioner Clinical Review Guideline, list a post-service or retrospective review will be performed prior to payment. The review will determine if the service or procedure is a covered benefit and if medically necessary.
Please refer to the links below to assist you with obtaining a prior authorization or benefit advisory:
The transition from hospital to home can be a vulnerable time for members from a continuity standpoint. Care Transitions is designed to support members as they transition from the hospital or care facility to the home setting or another care setting. It provides an integrated approach to support care coordination and access to appropriate follow-up care and programs.
Care Transitions helps members navigate the healthcare system. Through an assessment process, we recommend programs and services if you may be at early risk for health concerns. We also assist members in coordinating support services related to recovery and ongoing care.
Care Coordinators are Registered Nurses or licensed healthcare professionals. They will help facilitate healthcare needs and encourage health improvement.
If the member's recovery becomes longer term, the member is transferred to our complex case management team to coordinate further recovery and health improvement at a higher intensity level. Care Coordinators will continue to make follow up calls to members until members feel that they no longer need the support.
Case Management is a voluntary service offered to members with complex health conditions. Case Managers work cooperatively with our members and their physicians to identify, evaluate, plan and coordinate options and services to help members meet their healthcare condition, support better health outcomes and reduce hospital readmissions.
A LifeWise case manager (a nurse or social worker) serves as a single point of contact for members and their providers to:
Anyone can request assistance from a LifeWise case manager.
A LifeWise case manager will contact the referred member within five business days of receiving the request.