We understand that it can be frustrating when a request for a medical procedure is not accepted. To alleviate customer confusion, we will show you how decisions are made and provide helpful tips to avoid a denial.

How does a health plan, like Premera, determine what is covered under an individual’s plan?
Many services, drugs and procedures require approval from Premera before you receive them. This process is called prior authorization and is in place to make sure our members get the care they need and don’t get the care they don’t need. It also allows us to give you an estimate of your out-of-pocket costs before you accept treatment. 

So, what can you do prior to seeking care? 
Check first. Doctors who are in the Premera network can request preapproval for you; we also advise that you read your benefit booklet and understand your plan’s medical benefits and preapproval requirements before accepting treatment. If you have any questions, please reach out to customer support through the Premera app or call the customer service number on the back of your card and we will be happy to help you understand if a service, drug or procedure is covered or not. 

Why are some things covered and others aren’t? 
For a request to be processed and approved, it needs to meet medical necessity requirements. Health plans have clinical criteria that highlight the requirements for procedures and treatments. This clinical criteria includes medical policies and guidelines that are based on evidence-based data, scientific studies or guidelines published by reputable medical journals.

“Our clinical criteria follow the standards for Washington state and Alaska,” said Mary Hodge-Moen, care coordinator, Clinical Review at Premera. “Most hospitals use the criteria to help guide admissions and the length of stay for customers.”

Our medical policies are available on our website in a format that is easy to understand. Many are adopted directly from the Blue Cross Blue Shield Association and pharmacy guidelines. Most health insurers also use medical policies based on available scientific evidence. These policies are designed to comply with state and federal benefit mandates. 

Customers and their providers should consult the benefit plan booklet for any limitations. The customer’s benefit plan is the determiner of coverage even if a request is considered medically necessary.

Premera has a dedicated medical policy team, including physicians and nurses, that researches current medical literature and publishes all medical policies.

How do our medical policies protect our customers?
Premera wants to ensure that when a customer receives treatment, their quality of life is improved. Before a procedure or drug is deemed medically necessary, it must show in clinical studies to be safe and to give patients an improvement in their condition.

“In short, we want our customers to receive services that are proven to work,” said Taylor Donovan, manager of medical policy operations at Premera. “We want to keep our members safe.”

What happens if your prior authorization request is denied?
In the event of a denial, Premera strives to clearly explain why a request was not approved, said Hodge-Moen. You will be sent a letter containing information on why the request was denied and what to do next.

If you disagree, work with your provider to submit an appeal to your health plan – this is called a Level 1 appeal. Once an appeal is submitted, an appeals representative will review your request and any supporting documents to ensure a medical procedure meets medical necessity requirements.

Premera employs medical staff, including nurses and doctors, to review all appeals.  https://player.vimeo.com/video/371507591

Tips for submitting your appeal, from Meaghan Klassen, a member of the clinical review team at Premera

• Be an advocate for your own health. Work with your doctor to get the appeal right, as sometimes small details are overlooked that you might have the power to fix.
• Read the denial letter and look for the additional information requested by Premera.
• Review the clinical criteria referenced in the denial letter.
• Understand your benefits and read through your benefit documents.
• Contact your provider if you see something is missing in your medical record.
• Send it in on time, per the denial letter.

 
When an appeal is denied
If your Level 1 appeal was denied, you will receive a letter in the mail explaining why it was denied, who reviewed the request, along with suggested next steps. If you have any questions, reach out to customer support through the Premera app or call the customer service number on the back of your card. 

Alexandra Gunnoe is in Corporate Communications at Premera Blue Cross.