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Care Management

WSHIP’s Care Management program provides a variety of important services to enrollees.  The program was updated in 2011 and focuses on behavioral change through a whole person approach considering the physical, behavioral and social aspects of health to the overall well-being of enrollees.  Services include Utilization Management, Case Management and Care Coaching.  There is no cost to you to participate in these programs. 

Utilization Management:  Provides medical necessity reviews for all inpatient admissions and select outpatient services so you and your provider will know in advance if a service is considered medically necessary for coverage under your plan.  Closely monitoring prescribed procedures for medical necessity can also reduce non-essential treatments and their potential risks to your health.

  • While all services must be medically necessary to be covered under your plan, services that should be reviewed in advance for medical necessity are listed on the back of your ID card.  These services include:
      • Inpatient admissions prior to admission
      • Emergency admissions within 1 business day of admission
      • The following outpatient services:
        • home health care
        • rehabilitative therapies (physical therapy, speech therapy, occupational therapy, and respiratory therapy)
        • mental health visits
        • durable medical equipment
    • While your provider will generally initiate the review process on your behalf by calling our Utilization Management department, we encourage you to always confirm they have done so.  WSHIP will review the medical information submitted by your provider and make a determination of medical necessity for coverage purposes.  If a service is determined to not be medically necessary, we will send a letter to you and your provider notifying you of this determination and that the service will not be covered.  The letter will also explain how to appeal that determination.
    • If you have not obtained a medical necessity review in advance of the services listed on your ID card, WSHIP will request information from your provider upon receipt of your claim.   If the services are determined not to be medically necessary, they will not be covered by WSHIP. 

To request a medical necessity review or to check on the status of a review, call 1-800-549-7549.

Click here for information on how to appeal a medical necessity determination.

  • Case Management:  This service brings traditional medical and behavioral health strategies and interventions together in a clinically integrated approach for enrollees with complex or chronic medical conditions.  Case Managers help you to understand your choices, navigate the healthcare system, use your benefits wisely, and provide dedicated coordination on complex cases.  Case managers may:
    • Advocate on your behalf to ensure treatment plans are followed and to identify physical and/or behavioral health needs
    • Contact you to provide information and support your participation in the program
    • Assist you and your providers in establishing goals and milestones that drive clinical improvement, quality of life, education, and care facilitation and coordination
    • Conduct joint meetings with you and your medical and behavioral case managers
  • Care Coaching:  Our new Care Coaching program addresses underlying psychosocial issues associated with chronic diseases.  Health Coaches (RN’s and other licensed clinicians) provide support for your unique health situation.  Health Coaches work with you to:
    • Set goals to better manage and improve your health
    • Support follow-through on treatment plans
    • Increase understanding of lifestyle choices and their impact on medical conditions
    • Facilitate clear communication with doctors and other providers
    • Provide education on effective use of prescribed medications

To find out more about any of these programs, you or your provider can call 1-800-549-7549.

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