Our quality standards for our Texas members

Case management: Helping you manage all the moving pieces

As a Wellpoint member, we offer you 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 833-731-2160 (TTY 711). STAR Kids members, call 844-756-4600 (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 your providers.

Your case manager can also help with:
 

Setting up health care 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.

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.

Have questions about an approval or a denial?

Call Member Services at 833-731-2160 (TTY 711). STAR Kids members, call 844-756-4600 (TTY 711). Our Utilization Review team or your case manager can help answer your questions.

Appeals

You have the right to ask for an appeal if you don’t agree with our decision to deny or reduce a service. An appeal is when you ask us to review our decision.
 

You or your provider 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.

We’ll let you and your provider know when we get your request. Learn more about your appeal rights.

Your opinion matters

Every year, we survey our members about the benefits we offer. If you get a survey in the mail, by email or phone, please complete it. Your input helps us make your plan better.

New technology in medicine and care

To make sure we’re using the latest medical treatment and equipment to help you feel your best, our medical director and providers review the latest:

Medical treatment and services.
 

Behavioral health treatment and services.
 

Medicines.

Equipment.

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

If changes are safe and helpful.
 

If 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 that are listed in your member handbook.

Your benefits and how to get medical care

Are you looking to learn more about our services and benefits? In your member handbook you can read about:

Preventive health care for women: Learn how to access women’s health specialists for regular and preventive health care services.
 

Benefits and access to care: Find out more about your benefits and how to get medical care.
 

Language help: Learn how to receive our information in the language you use at home.

Care management: Learn how a care manager can help you get care for health issues.

Member rights and responsibilities: Read about your rights and responsibilities.

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). You can contact your provider for advance directive forms and more information.

Behavioral health (mental health and substance use disorder services)

If you or a family member needs help with behavioral health issues, call Wellpoint Member Services at 833-731-2160 (TTY 711). STAR Kids members, call 844-756-4600 (TTY 711). We’ll help you find a behavioral health specialist who can assist your needs.

You can also find a provider with our Find Care tool or by reviewing the provider directory. You don’t need a referral from your primary care provider to visit a behavioral health specialist.

Your benefits include medically necessary services such as:

Inpatient behavioral health services.
 

Outpatient behavioral health services.
 

Partial hospitalization.

Treatment and rehabilitative services.

Note: These services are not included for CHIP Perinate or Medicare members. Check your member handbook to learn more about your benefits. 

There are some treatments and services your behavioral health specialist must ask Wellpoint to approve before you receive care.

For information about services that need preapproval, visit our Referrals and Preapprovals page or reference your member handbook.

You can also contact Member Services at 833-731-2160 (TTY 711). STAR Kids members, call 844-756-4600 (TTY 711).