Policies and Procedures

Get coverage information

Covered benefits and services

To learn more about your plan benefits and services, refer to My LifeWise Plan Information, Summary of Benefits and Coverage, your member booklet, or contact Customer Service.

Limitations and exclusions of LifeWise health plans

Medical

LifeWise's medical plans do not cover all health care expenses and include limitations and exclusions. Please refer to your benefit booklet to determine which services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan may contain exceptions to this list based on state mandates, essential health benefits, or the plan design purchased.

• All medical and hospital services not specifically covered in, or that are limited or excluded by your benefit plan, including costs of services before coverage begins and after coverage terminates.
• Cosmetic surgery, except as specifically described in your member benefit booklet.
• Custodial care.
• Experimental and investigational procedures, services, and drugs, Implantable drugs (non-contraceptive related), and certain injectable drugs, including injectable infertility drugs.
• Infertility services including donor egg retrieval, artificial insemination, and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI, and other related services, unless specifically listed as covered in your plan documents.
• Non-medically necessary services or supplies.
• Radial keratotomy or related procedures.
• Reversal of sterilization.
• Services for the treatment of sexual dysfunction or inadequacies including therapy, supplies, or counseling.
• Special or private duty nursing.

Costs you might pay

To learn more about the costs you may have to pay, refer to My LifeWise Plan Information, Summary of Benefits and Coverage, your member booklet, or contact Customer Service.

View the summary of benefits and coverage

How am I protected from surprise costs?

First, when you visit a provider, make sure that everyone who participates in your care is in your plan network, including labs or tests.

Your rights and protections against surprise medical bills or balance billing

As of January 1, 2020, members of individual and family plans in Washington have the protection of the Washington Balance Billing Act. Beginning January 1, 2022, you have federal rights and protections against surprise medical bills or balance billing.

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is "balance billing”? (sometimes called, surprise billing)

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn't in your health plan's network.

"Out-of-network" describes providers and facilities that haven't signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay, and the full amount charged for a service. This is called "balance billing." This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

"Surprise billing" is an unexpected balance bill. This can happen when you can't control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

Insurers are required to tell you, via their websites or on request, which providers, hospitals, and facilities are in their networks. Hospitals, surgical facilities, and providers must tell you which provider networks they participate in on their website or on request.

You are protected from balance billing for:

When can you be asked to waive your protections from balance billing:

Health care providers, including hospitals and air ambulance providers, can never require you to give up your protections from balance billing. If you have coverage through a self-funded group health plan, in some limited situations, a provider can ask you to consent to waive your balance billing protections, but you are never required to give your consent. Please contact your employer or health plan for more information.

When balance billing isn't allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles) that you would pay if the provider or facility was in-network. Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must:
• Cover emergency services without requiring you to get approval for services in advance (prior authorization).
• Cover emergency services by out-of-network providers.
• Base what you owe the provider or facility (cost-sharing) on what it would pay an in‑network provider or facility and show that amount in your explanation of benefits.
• Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you've been wrongly billed, you may:

File a complaint with the federal government
By phone: 800-985-3059
Online: https://www.cms.gov/nosurprises/consumers/


File a complaint with the Washington state Office of the Insurance Commissioner
By phone: 800-562-6900
Online: https://www.insurance.wa.gov/file-complaint-or-check-your-complaint-status


For more information about your rights, visit:

https://www.cms.gov/nosurprises

https://www.insurance.wa.gov/what-consumers-need-know-about-surprise-or-balance-billing

Find a doctor or other providers and get primary care

LifeWise wants to make sure you are getting the care you need. Annual check-ups can identify problems early, before they become more serious. Regular visits with your doctor also allow you to discuss any health concerns you may have including more complex health conditions you may have.

You may seek specialty care and behavioral healthcare from in-network or out-of-network providers. Be sure to talk with your primary care provider about your preferences. Depending on your plan, you may need a referral from your primary care provider in order to access specialty care. Refer to your member benefit booklet for details.

Participating in-network providers and facilities are listed in Find a Doctor. Sign in to see providers in your network. Certain nonemergency hospitals and other medical services require preapproval from LifeWise. Contact us if you have difficulties finding a provider or have other questions.

Note: If you are enrolled in an EPO plan, in most cases you are only covered for services from in-network providers. Sign into your online account to use Find a Doctor or refer to your member benefit booklet for details.

Finding specialist, behavioral health, or hospital care resources

Members may seek specialty care and behavioral healthcare from in-network or out-of-network providers. Be sure to talk with your primary care provider about your preferences. Depending on your plan, you may need a referral from your primary care provider in order to access specialty care. Refer to your member benefit booklet for details.

Participating in-network providers and facilities are listed in our online Find a Doctor directory. Sign into your online account to find providers contracted with your specific plan. Certain non-emergency hospitals and other medical services require preapproval from LifeWise. Customer Service can assist you with the directory or help you locate a practitioner or facility within a specific geographic area.

Please note: If you are enrolled on an EPO plan, in most cases you are only covered for services from in-network providers. Sign into your online account and refer to your member benefit booklet for details.

After-office-hours or emergency care

You have options if you need after office hours or emergency care. Sometimes it's hard to know what to choose, but there's a big difference in time and money.

24-Hour NurseLine

Call our free and confidential 24-Hour NurseLine to speak with a registered nurse who will ask the right questions, listen to your concerns, and help you determine where and when to seek treatment. The NurseLine number is listed on the back of your ID card. Note: if there isn't a NurseLine number on your card your plan may not participate with the NurseLine service.

Non-Life Threatening

Urgent care facilities provide quick, convenient care for health needs that aren't life threatening but can't wait until the next day or longer. They are open outside of regular business hours and are less expensive than emergency room care. To locate the nearest urgent care facility, search our Find a Doctor directory.

Conditions that can be dealt with in an urgent care facility:

• Ear infections
• Low fever or mild flu symptoms
• Minor rashes, cuts, bites, and sprains

Life Threatening

Call 911 or go to the emergency room if you are in severe pain or your condition is endangering your life. To locate the nearest ER, search our Find a Doctor directory.

Examples of medical emergencies:

• Suspected heart attacks
• Strokes
• Broken bones

Out-of-area care and benefit coverage

If you have a LifeWise plan and travel outside the area covered by the primary network, you only have coverage for emergencies. If you are on a LifeWise grandfathered plan your out-of-area coverage is different. Check your member booklet for details.

Prescription drugs

LifeWise members have access to a comprehensive, nationwide network of retail pharmacies and access to a convenient mail order pharmacy, Express Scripts Home delivery. To find information about your drug benefits use the following links.

Find a network pharmacy near you:
Find an in-network pharmacy

View pharmaceutical management procedures (procedures that affect your drug coverage):
View drugs that require Prior Authorization (exception requests)
Learn how to obtain coverage for non-formulary drugs if you have a closed formulary plan
View drugs subject to Preservice review

View your drug list and see which drugs have limitations to prescribing or access:
Search drug lists
Visit Express Scripts to view your personalized pharmacy benefits

Learn how to obtain restricted pharmaceuticals:
Use drug lists to learn which drugs have restrictions, quantity limits and step therapy
Visit Express Scripts to find your copay for a restricted prescription
Learn about prescription mail-order

Save money with generics

Generic drugs have been proven to be as effective and safe as brand-name drugs. They may come in different shapes and colors than their brand-name equivalent, but they contain the same active ingredients, and are available in the same strength and dosage. On average, a member can save up to $222 a year by using a generic drug instead of a brand-name drug. Learn more about the Food and Drug Administration's (FDA) approved drugs.

Before filling a prescription, always ask your provider/pharmacist:

• Is this drug available as a generic?
• Is there a low-cost generic available within this group of drugs that works the same?

Health plan information

Information about our Utilization Management Program

The goal of the Utilization Management program is to promote the delivery of appropriate, effective, and efficient medical care to our members. This includes medical services, medical equipment, and pharmacy. If you have questions about the Utilization Management Program, please contact Customer Service.

Our policy on prohibiting financial incentives

LifeWise and its delegates do not reward or pay our staff based on how members use healthcare services. We do not base their pay in any way on how or if they decide to approve or deny coverage. We do not reward or pay our staff to make decisions that cause members to use fewer healthcare services.

We do review some healthcare services before members get them. These reviews help us decide if and how to cover those services. When we do a review, we look only at whether services meet medical criteria for your condition and whether your plan covers them.

“We” includes LifeWise and any of its delegates, and any people or organizations we hire to review requests.

Information about our Quality Program

LifeWise is committed to assuring quality care for its members. Our Quality Program makes sure that the healthcare our members receive is evaluated, measured, improved, and communicated about. LifeWise’s Quality program is designed to improve members’ health and the quality and safety of care and service. The Quality Improvement Committee conducts a formal, system wide quality assessment annually which includes an annual program evaluation of the quality of its health services.

How new technologies become covered services

Teams of doctors, pharmacists, and nurses review new drugs and medical services. The Medical Policy Committee reviews new technology and other medical or surgery services. The Pharmacy and Therapeutics Committee reviews new drugs and some therapies. These committees decide if a new drug or service will be covered. Their decisions are based on sound published scientific studies. Their decisions help protect against the use of treatments that are not proven or not safe.

Health and safety information

Safety information

It's important to think about safety when you need healthcare. Talking with your doctor is perhaps the most important link to better care and health results. The links provide useful tools to help you talk with your doctor about care and medications.

Check out Five Steps to Safer Healthcare to learn more.

Medication list

For a Medication List in English and Spanish and a variety of Tips and Tools related to medications, go to: http://www.safemedication.com/

10 questions to ask

Asking questions is important to safe care! The Agency for Healthcare Research and Quality provides useful resources including The10 Questions You Should Know

Ask Me 3™

The Ask Me 3™ is a program designed to promote communication between health care providers and patients in order to improve health outcomes. The program encourages patients to ask and understand the answers to three questions:

• What is my main problem?
• What do I need to do?
• Why is it important for me to do this?

Learn more by visiting: Institute for Healthcare Improvement.

5 Steps to safer care

Agency for Healthcare Research and Quality.

How to access your personal health records

To request certain records containing your personal information complete the request for Inspection of Records form. To share your personal records you can use the Information Release Form—Give someone permission to obtain and discuss your personal and health information, including sensitive information such as substance abuse, reproductive health, and mental health. You can also authorize members on your plan to see your sensitive information on lifewise.com or ConnectYourCare (medical funding account).

How to get support for a chronic condition

Personal Health Support

LifeWise offers help to support to our members, their spouses/domestic partners, and dependents who are enrolled in a LifeWise plan and are diagnosed with a chronic condition such as asthma, coronary artery disease, heart failure, chronic obstructive pulmonary disease, diabetes, or depression. Personal Health Support encourages healthy lifestyle changes and helps develop self-management strategies for better health. This program is available at no cost to you.

Tools and resources

Participants have access to a personal health support team of registered nurses, certified dietitians, and licensed mental health professionals with expertise in chronic condition management. The program also includes:

• Regular, pre-scheduled telephone sessions with a care advisor to develop a personal care strategy. These calls are meant to help monitor symptoms, better manage the health condition, promote regular exercise, and improve nutrition.
• Educational materials, health monitoring tools, and newsletters developed for specific conditions.
• Help for understanding tests and prescription medications.

Participation is voluntary, and you can withdraw at any time.

3 ways to join

• LifeWise identifies you as someone who can benefit from the program, based on your previous claims and reaches out to you directly.
• Your doctor or another healthcare provider refers you to the program and LifeWise contacts you.
• You can call LifeWise at 1-800-817-3056 (711 TTY/TDD for the hearing impaired).

NOTE: For benefit and claims questions, please either contact the Customer Service number on the back of your insurance card or you may also email from your Secure Inbox.

More information

Diabetes
diabetes.org
cdc.gov
nih.gov
win211.org

Asthma
lung.org
nhlbi.nih.gov
cdc.gov
win211.org

COPD
lung.org
goldcopd.org
nhlbi.nih.gov
cdc.gov
win211.org

Coronary Artery Disease (CAD) and Heart Failure
heart.org
nhlbi.nih.gov
win211.org

How to get help from a care advisor

Personal Health view offers support to help you or a family member with serious health problems. With this service, a care advisor will help you with any concerns you have with your health or care. This service is voluntary and free as part of your health plan.

Your Personal Approach to Health (PATH)

LifeWise Health Plan of Washington is committed to helping you get healthy and stay well. Care Advising services are offered as part of your PATH, if you need additional support managing your health.

Care Advising services are included in your plan at no additional cost.

To enroll or get more information, call 800-817-3056. TTY: 711

Learn more about pre-approvals

Make sure you're covered

Don't be surprised by a bill you weren't expecting

Did you now that you may be required to get an approval for coverage from your health plan before you have a planned medical service or procedure? This is called a pre-approval, and it helps you:

• Find out if you're covered by your benefits before you have your scheduled procedure
• Save money and avoid extra costs
• Get an estimate of your out-of-pocket for copay and deductible costs before you get your service
• Avoid unnecessary services

Learn more about pre-approvals

View the list of services and drug treatments requiring prior authorization.

Services that do not require pre-approval

• Hospital admission for prenatal, childbirth, and newborn care.
• Emergency admission to hospital.
• Office visits to a primary care doctor, family doctor, or specialist.

Pharmacy pre-approval program

If you have a prescription plan benefit, some drugs must be approved for coverage through our pharmacy pre-approval program.

Learn more about drugs requiring pre-approval

Your rights and resources

Your rights and responsibilities as a health plan member

These are your rights as a health plan member:

• You can easily get information about the organization, its services, its practitioners and providers
• You can easily get information about your member rights and responsibilities.
• We will treat you with respect. We will recognize your dignity and right to privacy.
• You can work with your healthcare provider to decide on treatments you need.
• You can talk honestly about the treatments that are right for your conditions, regardless of cost or benefit coverage.
• You can make complaints or appeals about us or the care or service we provide.
• You can recommend changes to our member rights and responsibilities policy.
• You can choose your healthcare providers.
• We will keep things you tell us about your health claims and other related information private.
• Your healthcare and healthcare coverage information will stay protected.
• You can review and get copies of your personal information on file.
• You can get screening and stabilization emergency services when and where you need them. You do not need prior authorization, regardless of cost or benefits coverage. This applies if severe pain, injury, or sudden illness convinces you that your health is at great risk.
• You can continue to get care from our specialty provider for up to 90 days or until you complete your care. This applies if you are getting treatment for a chronic or disabling condition. It applies if you are in your second or third trimester of pregnancy. It applies when you involuntarily change your healthcare plan. It applies if your provider leaves the network for any reason other than cause.

These are your responsibilities as a health plan member:

• Give as much of the information as you can that LifeWise and its providers need in order to provide care.
• Follow plans and instructions for care that you have agreed to with your providers.
• Try to understand your health problems.
• Work as much as possible with your healthcare providers to develop treatment goals you can agree on.
• Try to keep healthy habits, such as exercising, not smoking, and eating a healthy diet.
• Disclose relevant information. You must try to communicate clearly what you want and need.
• Avoid knowingly spreading disease.
• Understand your healthcare provider's obligation to provide care equally and efficiently to other patients and the community.
• Learn about your health plan coverage and options, including all covered benefits, limitations and exclusions, and rules about the use of information.
• Understand how to appeal coverage decisions.
• Show respect for other patients, health workers, and health plan employees.
• Make a good-faith effort to meet financial obligations.
• Follow the administrative and operational procedures of your health plan and healthcare providers.
• Report wrongdoing and fraud.

How we use your personal health information

At LifeWise, we are committed to maintaining the confidentiality of your medical and financial information. The Notice of Privacy Practices informs you about how we may collect, use, and disclose your personal information and your rights regarding that information.

How and when to send us a request for reimbursement

When you receive care from providers in the network, they will process your claims directly with us, so you don't need to handle any paperwork. However, if you receive care from a non-network provider, you may have to pay the provider for the service and then file a claim with us for reimbursement.

To file a claim for reimbursement, simply follow these steps:

• Complete and sign the form.
• Staple an itemized bill from the provider for the covered service.
• Mail your claim to the address shown on the form.

Please see your Benefit Booklet for more details on filing claims.

Request a Claim Review

If you disagree with how a claim was paid as described on your Explanation of Benefits (EOB), you can request a review. We must receive your request to review a Claim within 180 days after you receive your EOB. You can either call Customer Service or submit a written request. If you suspect that payments were made for services you didn't receive, please call the Anti-Fraud Hotline at 800-848-0244.

Submit a Written Request

If you prefer, you can submit a written request so you can make a copy for your records. Along with your written request, include a copy of the EOB to identify details of the disputed claim and any other documents or information that may help resolve your claim to your satisfaction. After we receive your request, we will send you detailed information about our appeals process, including the timeframes for each step of the process. Send your request to:

LifeWise Health Plans of WA
P.O. Box 21552
Eagan, MN 55121

Questions? Concerns?
Please contact Customer Service.

Language assistance

To get language assistance, contact Customer Service.

TDD/TTY services

Our TDD/TTY number for deaf or hard of hearing members is 711.

How to submit a complaint, your right to appeal, and availability of independent external review

You can make complaints about:

• The care or service we provide.
• The quality or availability of a healthcare service.
• The care or service you get from any providers in our network.

You also have the right to appeal any action we take or decision we make about your coverage or services.

Get additional information about how to file a complaint, appeal, or request an external review.

Understanding your explanation of benefits

Each time LifeWise processes a claim submitted by you or your healthcare provider, we explain how we processed it in the form of an explanation of benefits (EOB).

The EOB is not a bill. It simply explains how your benefits were applied to that claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid and any balance you're responsible for paying the provider. It also tells you how much has been credited toward any required deductible.

Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider.