Care Management

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:

• Hospitalizations, partial hospitalizations
• Elective outpatient surgeries
• Admission to a skilled nursing facility or rehabilitation facility
• Non-emergency and elective air ambulance services
• Organ transplants
• Home health/home infusion
• Advanced imaging
• Supplies, appliances, HME and prosthetic devices over $500 (purchase, repair or total rental)
• Provider administered drugs

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:

• Advanced Imaging Services subject to review: CPT Code List
• Radiology requests for CT, MRI, MRA, and Nuclear Cardiology must be submitted through American Imaging Management

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.

Care Coordinators are available to:

• Offer education and pre-planning activities prior to undergoing surgery or procedures
• Work with the inpatient facilities to assist with safe discharge planning for serious illness or injury that may require intensive follow up care
• Help understand what coverage is in place for the planned treatment
• Provide education and support following discharge after a health event that may require coordination of homecare - for example, intravenous (IV) care, rehabilitation to other related services. It also includes providing assistance to members and their families to better understand prescribed medications and information to support treatment plan adherence.

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:

• Ensure members receive the right amount of care, in the right place, at the right time
• Understand available healthcare benefits
• Ensure members understand their providers plan of care and help them overcome barriers to adherence to that plan, and
• Serve as a liaison for providers with the health plan.

Case Management Referral Process

Anyone can request assistance from a LifeWise case manager.

1. If you are initiating a referral on behalf of a member, please provide the following information:
• Member name, health ID#, and suffix
• Contact name and number
• Reason for the referral and expected outcomes
2. Fill out the form, print it, and fax to LifeWise Case Management at 877-468-7377.

A LifeWise case manager will contact the referred member within five business days of receiving the request.