Care Management

  • Services available through LifeWise Care Management programs help members navigate the healthcare system with a range of options available to:

    • Help members and their healthcare provider determine coverage for specific services and procedures;
    • Provide care coordination and support if a member or one of their family members is dealing with a complex medical condition, and
    • Provide care education and planning guidance ahead of a planned hospital stay or following discharge and transition to the member's home.

    Care management programs

    Prior Authorization for Medical Necessity

    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

    Prior authorization is a contractual requirement for a patient or provider to obtain approval from a health plan in advance of certain services. For members with a plan subject to prior authorization, this pre-service review will be required to determine medical necessity and coverage for inpatient services and various outpatient services, supplies, and drugs.

    For a list of procedures and services that require prior authorization, see the Clinical Review by Code List.

    Pre-Service Review

    A pre-service review is used to determine if a service meets medical necessity criteria and if the member's plan includes the benefit. A pre-service review is not a requirement nor is it a guarantee of payment. If a pre-service review has not been requested for a service or procedure on the Clinical Review Code List, we will do a retrospective (or post-service) claim review before payment. A retrospective review could result in provider or member financial liability - to avoid this, we recommend a pre-service review.

    Healthier outcomes for moms and babies

    BestBeginnings Maternity

    LifeWise's maternity program, BestBeginnings, provides maternity and newborn programs for eligible members:

    • Best Beginnings Maternity Program: Provides education and support services to pregnant members through the BestBeginnings mobile app and case management services for those eligible members identified as high-risk.
    • Special Care for Baby: Provides case management on site or by phone, and assists facility staff in providing discharge planning, support, and resources for parents. It also includes concurrent review for neonatal intensive care unit (NICU) services. LifeWise partners with AlereTM for this part of the program.

    Alere is a trademark of the Alere group of companies.

    Care transition management

    Consumers are responsible for more of their healthcare decision-making than ever before. Healthcare decisions can be the most difficult, challenging, and stressful issues for families to deal with. The burden and stress placed on consumers to manage their way through the complexities of today's complex healthcare system are significant.

    Care Transition Management provides expertise in assisting members through the healthcare system. Through an assessment process, we recommend programs and services for members who may be at early risk for health concerns. Our Care Transition Management program supports members during transition from home to hospital and hospital to home.

    Our licensed clinical staff provides the following services:

    Preadmission Member Outreach

    One of our licensed clinicians helps prepare the member for a positive transition, even before the member has been admitted to the facility by:

    • educating the member about their treatment plan
    • assessing the needs of the member and their family or other key caregivers
    • identifying potential barriers to care
    • developing a plan for optimal post-discharge care.

    Collaborative Discharge Planning

    Our clinical staff works with members and providers to coordinate safe discharge plans and post-discharge care needs.

    Concurrent Review

    Care Transition Managers ensure quality of care for members through concurrent review during a member's inpatient stay. By monitoring medical necessity, our members receive appropriate care at the appropriate level, for the appropriate length of stay.

    Readmission Prevention

    A clinician provides outreach to members within 72 hours of discharge notification to identify barriers to optimal recovery, promote treatment adherence and encourage recommended follow-up care. Care Transition Managers follow the member's care upon discharge for health events that require short-term coordination of homecare, IV, rehabilitation or other related services. If the member's recovery becomes longer term, the member is transferred to our complex case management team which coordinates further recovery and health improvement at a higher level.

    Integrated case management

    This voluntary service is offered to participants with health complexity, high utilization, and functional impairment. Health complexity encompasses multiple diagnoses, physical and mental health co-morbidities, personal, social, and financial upheaval, and health system issues. Integrated Case Management works cooperatively with members and physicians to identify and overcome clinical and non-clinical barriers to improve health outcomes.

    How to refer your patients for Integrated case management services

    Providers can refer eligible LifeWise members to receive personal health support by calling 800-596-3440. The team is available to take referrals by phone and answer questions Monday through Thursday, 6 a.m. to 7 p.m., PST, and Fridays, 6 a.m. to 6 p.m. You can also email us at case.management@lifewisehealth.com.