There are a number of reasons your company offers health insurance to employees as a part of a comprehensive benefits package. Sure, it may be a prime benefit to attract and retain talent. But, the most important reason? Accidents — and life — happen.
Offering health insurance makes sure your employees have access to the care they need, when they need it most.
However, it’s important for both you and your employees to know that some services, procedures, tests and medications may require different approvals.
But, why?
Simply put, this ensures your employees’ care is appropriate, timely and safe, and avoids costly, unexpected medical bills. For Wellmark Blue Cross and Blue Shield customers, check out this comprehensive list Opens in a new window of certain procedures, services or admissions requiring further approvals.
First things first: Is your employee or the provider responsible for the pre-service approval?
To put it into perspective, let’s say you have an employee who has a complex medical issue and their primary care provider recommends a procedure that will require Wellmark approval. What happens next?
- If this employee’s primary care provider is in-network, they will typically complete the approval on their behalf.
- Out-of-network providers in Iowa or South Dakota are not required to handle the approval process.
- Always encourage your employees to ask their provider if they’ve fulfilled approval requirements before care is given.
- If the out-of-network provider doesn’t submit for approval, have your employee call the phone number on the back of their ID card before they receive services.
The utilization management (UM) process
Now to utilization management (UM), an important process for both you and your employees to have a better idea of why requests are approved or denied.
- Primary care provider recommends procedure requiring medical approval before benefit administrator will cover it.
- Primary care provider submits an approval to the insurance carrier.
- Insurance carrier reviews the request.
- Yes or No? Request is approved or further reviewed.
- If no, Further review: A UM nurse looks at medical guidelines to make the approval. Requests that don't meet the guidelines are sent to the insurance carrier medical director(s) for further review.
- Yes or No? Medical director(s) determine whether requests are approved or denied
Approved or denied: What are next steps?
After the decision is made by your insurance carrier's designated medical director, there are a few things to keep in mind.
- The decision is always noted in the member’s records.
- Some members, who may benefit from it, are enrolled in an Advanced Case Management Program.
If the claim is approved:
- The member and their provider are both sent letters to let them know the procedure is approved.
If the claim is denied:
- The member and their provider are both contacted via telephone to let them know the service is not approved. A decision letter is sent to both the member and provider. The letters give a reason for the denial and explain how an appeal can be made.
- Either the member or provider may file an appeal to assert the procedure is medically necessary.
- Peer physicians are available to discuss member cases with the member's provider. The provider may have new evidence that supports reversing the decision.
What can you do for your employees?
As an employer, it is important to review the UM reporting data available to you. This data can highlight focus areas for employers to improve the health choices made by their employees. Also, any employers with members living outside Iowa and South Dakota should let their employees know they must pre-certify facility and home-health admissions.
Terms to know: Utilization Management Glossary
There are a number of ways your employees can seek approvals, and often terms are used interchangeably. Use this list of approval types to help clear up any confusion when your employees go through a pre-authorization process.
Notifications: Alert your insurance carrier of facility admissions and discharges.
Out-of-network referral: A review for benefits when specific medical expertise is unavailable in-network.
Prior approval: A review for medical necessity for a treatment, procedure, service or supply.
Prior authorization: A medical necessity review for drugs and drug-related treatments.
Preauthorization: Provides approval of outpatient diagnostic imaging services.
Precertification: A review for medical necessity required for certain types of admissions.
Questions? Contact your authorized Wellmark representative, or email us at blueatwork@wellmark.com Send Email .
