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We provide a wide range of medical management programs designed to support our members at any stage of health. These programs are targeted to specific conditions or are designed to improve or maintain overall health.

The goals of our medical management programs are to:

  • Ensure our members receive appropriate care
  • Assist our members with managing a limited benefit
  • Enable us to be responsible stewards of the cost of health care

Dental care management

We apply appropriate dental care management procedures to ensure that treatment provided:

  • Is consistent with widely accepted standards of practice
  • Could not have been omitted without adversely affecting the patient's condition or quality of care
  • Is not primarily for the convenience of the patient, the participating dental provider or any other person
  • Is the least costly appropriate treatment and location that can be used safely to treat the patient's condition
  • Is the appropriate type, level, amount and frequency of care necessary to treat a dental condition or injury that is harmful to the health of a patient
  • Physical medicine

    We partner with eviCore Healthcare (eviCore) to manage our Physical Medicine program. Services managed under the Physical Medicine program include:

    • Arthroscopy
    • Joint replacement
    • Chronic pain management (except pain management handled through pharmacy benefits)
    • Select spinal surgery procedures
    • Physical, occupational and speech therapy treatments
    • Complementary and alternative medicine (chiropractic, acupuncture and massage therapy)
  • Radiology

    AIM Specialty Health administers the two components to our radiology program: Radiology Quality Initiative (RQI) and Advanced Imaging Authorization. Services managed under our radiology program include:

    • Nuclear cardiology
    • Positron emission tomography (PET)
    • Magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA)
    • Computed tomography (CT)/computed tomographic angiography (CTA)
    • Stress echocardiography (SE)/resting transthoracic echocardiography (TTE)/transesophageal echocardiography (TEE)
  • Sleep medicine

    We partner with AIM Specialty Health to manage our Sleep Medicine program. Services managed under the Sleep Medicine program include:

    • Titration studies
    • Home sleep testing (HST)
    • Oral appliances for sleep therapy In-lab sleep studies (polysomnography [PSG])
    • Initial and ongoing treatment orders for automatic positive airway pressure (APAP), continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP)
  • Care management

    Care management delivers a personalized model that focuses on each member holistically. This model provides members with the greatest unmet health care needs with a single case manager to support their medical and behavioral health. Our case managers are an extension of the member's provider team and support each member in meeting their health care goals.

    PreManage for patient care coordination
    We partner with Collective Medical Technologies (CMT) to provide PreManage, a secure, web-based care management system that provides real-time information about patients.

  • Peer-to-peer review

    A peer-to-peer (P2P) review is a telephone conversation between a licensed Regence physician or clinical reviewer and the physician or other health care professional requesting authorization for coverage or to discuss a denial of a provider-administered medication pre-authorization request. A P2P is not an appeal and is not intended to overturn the denial. The purpose is to further understand the reason for the denial based on our medical or medication policies.

  • Personalized Care Support

    Our palliative care program focuses on supporting the health care needs of our members and their families at any stage of life or illness. Our services for members with serious or life-limiting illness allow for individualized care that could include home health aides, in-home counseling and increased access to help via phone. In addition, our Personalized Care Support program offers services for members with serious illness through specialized care management.