Our quality standards

Striving to do better, every day

Your health is important to us. We work hard to make sure you can get great care when you need it. We do this by:

• Having programs and services to help make sure the quality of healthcare you get is even better.
• Supporting pregnant members and new parents with tools and information.
• Finding local programs in your community to help you get the services you need.
• Hosting events to help you learn about your plan and get the most out of it.
• Following state and federal rules.
• Looking at our quality reports to find new ways to offer better care.

Learn more about Quality Management

Have questions about the Quality Management program?

Call us. We can also send you information on our Quality Management program. We can talk to you about:

• What quality management is.
• How we are doing and what our goals are.
• How we are working to make things better for you.

Call Quality Management at 833-707-0867 (TTY 711).

Case management

Helping you manage all the moving pieces

Healthcare can be overwhelming. Our case managers can help make it easier. Your providers know how to help you with your care. It really helps if you know how to care for yourself, too. That's what our case managers do.

As an Wellpoint member, we offer many different types of services. Your case manager works with you and your provider to set up a plan of care. You may already be working with a case manager and know how to contact them.

If you think you need case management services or need help contacting your case manager, call us at 833-707-0867 (TTY 711).

Our case managers may also call if:

• You or your doctor thinks case management might help you.
• You've just gotten out of the hospital and need help with follow-up visits to other providers.
• You're going to the emergency room (ER) often for nonurgent care that could be handled by your provider.
• You call our 24-hour Nurse HelpLine and need more follow-up for ongoing care.
• You have serious physical problems and need more help.
• You have behavioral health problems and need more help working with all of your providers.

Your case manager can also help with:

• Setting up healthcare services.
• Getting referrals and prior authorizations (approvals).
• Checking your plan of care.

If we call you, a nurse or social worker will:

• Always identify themselves with their name, title, and position with Wellpoint.
• Tell you about what we offer.
• Talk to you about your health and how you're handling different parts of your life.

Utilization management

How we make choices on care and services

Sometimes, we need to make choices about how we pay for care and services. This is called Utilization Management (UM).

Our UM program:

• Looks at what, when and how much of our services are medically needed.
• Always strives for the best possible health outcomes for our members.

Our UM program does not:

• Tell doctors to withhold or give you fewer services limiting or denying care.
• Stop certain people from getting services.
• Reward doctors for limiting or denying care.

Getting in touch with our Utilization Management staff

Some Wellpoint services and benefits need prior approval. This means your provider must ask Wellpoint to approve the services they want you to have. Services that don't need approval are:

• Emergency care
• Care needed after a hospital stay
• Our Utilization Review team looks at approval requests. The team decides if:
  • The service is medically needed.
  • The service is one that is included in your Wellpoint benefits.

What should you do if Wellpoint won't approve care you think you need?

You or your provider can ask us to take another look. We'll let you and your provider know when we get your request.

You can ask us to take another look at services that:

• Are not approved.
• Have been limited in the amount or length of time from what was requested.

Do you have questions about an approval or a denial you got?

Call Member Services at 833-707-0867 (TTY 711). Our Utilization Review team or your Case Manager can help answer your questions.

New technology in medicine and care

To make sure we are always using the latest medical treatment and equipment to help you feel your best, our medical director and providers look at all the latest medical changes. They look at:

• Medical treatment and services.
• Behavioral health treatment and services.
• Medicines.
• Equipment.

They also look at the most up-to-date medical and scientific writings. With all this data, they consider:

• If the changes are safe and helpful.
• If these changes offer the same or better results than what is used today.

This work is done to help us decide if a new treatment or care should be added to your benefits.

You have rights and responsibilities

As a Wellpoint member, you have rights and responsibilities. They are listed in your member handbook. Do you need a printed copy of your member handbook?

Call Member Services at 833-707-0867 (TTY 711).

Your benefits and how to get medical care

Are you looking to learn more about our services and benefits? Grab your member handbook.

You can read about:

• Preventive healthcare: Find out how to help prevent many health issues and how to live a healthier life.
• Preventive healthcare for women: Learn how to get access to women's health specialists for regular and preventive healthcare services.
• Benefits and access to care: Find out more about your benefits and how to get medical care.
• Language help: Learn how to get our information in the language you use at home.
• Case management: Partner with a case manager to learn more about ways to get care for your health issues.
• Member rights and responsibilities: Read about your rights and responsibilities.
• Notice of Privacy Practices: Learn more about how we keep your private information safe.
• Medical necessity: Find out how we decide if care is right for you based on the right coverage and correct levels of care and service.
• Advance directives: Learn more about your right to use an advance directive (living will), to have one on file or on hand if you can't tell others about the care you want to keep you alive. Your provider has advance directive forms and more information.

Our Notice of Privacy Practices

The notice tells you about how we may use and share your health data. It also tells you how to get this data. The notice follows the Privacy Rule set by the Health Insurance Portability and Accountability Act (HIPAA). Our Notice of Privacy Practices is in your member handbook as well as online. Live chat with a representative and let them know if you want a copy of the Notice of Privacy Practices mailed to you.

Not a kid anymore? It may be time for a new PCP

As you become an adult, your healthcare needs start to change. If you're seeing a pediatrician, you may want to find a primary care provider who treats adults.

Adult PCP offices include:

• Family practice
• General practice
• Internal medicine

Start by asking your current PCP for a recommendation for a new adult PCP. We're here to help, too. You can change your PCP at any time. It's easy with our Change Your PCP tool.