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Pre-Service Review Changes

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 

 

Education & Training

 

Learn about education and training opportunities.

 

User Guides

 

Utilization Management - Inpatient 

 

Utilization Management - Procedures and DME 

Utilization Management - Out of Network 

 

Utilization Management Services may be delegated.

 



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