Pre-service review changes are currently underway at Wellmark Blue Cross and Blue Shield. The focus is to:
- Streamline the pre-service review process to make it more efficient for providers and for Wellmark.
- Reduce the volume of retrospective reviews.
Why are these changes occurring?
- Using utilization management to ensure the right care is delivered at the right time is one solution to ensure services meet evidenced-based medical necessity criteria.
- The enhancements focus on improving quality and lowering costs and leveraging electronic capabilities so that both providers and Wellmark can work more efficiently and effectively.
- Because the focus is on the review before the service is provided, post-service review activity will decrease, helping to reduce claim adjudication timeframes and provider recoupment.
Pre-Service Review Definition
- The process of determining if a medical procedure, equipment, or hospital admission is medically necessary before the service is provided.
- Pre-service review program benefits:
- Helps ensure care follows nationally approved guidelines.
- Helps ensure care is medically necessary.
- Helps to reduce practice pattern variation.
Three Key Program Components
Learn more by clicking a specific program component below.
Frequently Asked Questions
Pre-Service Review Frequently Asked Questions
Utilization Management - Inpatient
Utilization Management - Procedures and DME
Education & Training
Learn about education and training opportunities.