Our quality standards for West Virginia
Your whole health is our whole point
We work hard to make sure you can get great care when you need it. We do this by:
- Having quality programs and services for your healthcare.
- Supporting pregnant members and new parents with tools and information.
- Finding local programs to help you get the services you need.
- Hosting events to help you get the most out of your plan.
- Following state and federal rules.
- Reviewing quality reports to find new ways to offer better care.
What’s the Quality Management program?
If you have questions about our Quality Management program, call us. We can talk to you about:
We can also send you information on our Quality Management program. Just call the Customer Care Center at 800-782-0095 (TTY 711), Monday through Friday from 8 a.m. to 6 p.m.
You can also ask any Quality Management program questions on the SydneySM Health app with live chat.
Bringing you quality healthcare in WV
Did you know Wellpoint is a NCQA accredited health plan in West Virginia? This means we’re committed to quality healthcare and keeping members healthy.
Yearly quality update
Our Quality Management program keeps track of member services and satisfaction.
Case management: Helping you manage all the moving pieces
As a Wellpoint member, we offer many different types of services. Your case manager works with you and your primary care provider (PCP) 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 the Customer Care Center. The phone number for your plan is on our Contact us page.
Our case managers may also call if:
You or your primary care provider (PCP) thinks case management might help you.
You’ve just checked out of the hospital and need help with follow-up visits.
You’re going to the emergency room (ER) often for nonurgent care that could be handled by your PCP.
You call our 24-hour Nurse HelpLine and need more follow-up for ongoing care.
You have serious health conditions and need more help.
You have behavioral health issues and need more help working with your providers.
Your case manager can also help with:
Setting up healthcare services.
Getting referrals and 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 care.
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 providers to withhold, deny, or limit care.
Give you fewer services.
Stop certain people from getting services.
Reward providers for limiting or denying care.
Getting in touch with our Utilization Management staff
Some Wellpoint services 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
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.
If you have questions about an approval or a denial, call the Customer Care Center number listed on your member ID card. 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.
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 fill it out. It helps us make your plan better.
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 advances.
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 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.
Your rights and responsibilities
As a Wellpoint member, you have rights and responsibilities. They are listed in your member handbook.
Need a handbook mailed to you?
Ask for a handbook on live chat from a Wellpoint representative.
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 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 how to get 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.
Pharmacy—Find out about your benefits and how to get the medicines you need. Your pharmacy benefits are covered under the state Medicaid program and managed by Gainwell Technologies.
Case management—Talk 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). Having one on file can tell others about the care you want to keep you alive. Your provider has advance directive forms and more information.
Mental health and substance use disorder (SUD) services
If you or a family member needs help with mental health, please call the Wellpoint Customer Care Center. You can get the name of an in-network mental health specialist who will work with you to make a treatment. You can also find a provider with our Find Care tool or by checking the provider directory.
Your benefits include many medically needed services, such as:
- Inpatient behavioral health services
- Outpatient behavioral health services
- Partial hospitalization
- Treatment and rehabilitative services
Check your member handbook to learn more about your benefits.
You don’t need a referral from your primary care provider (PCP) to visit a behavioral health specialist in your plan. However, there are some treatments and services your mental health specialist must ask Wellpoint to approve before you can get them. For information about services that need prior authorization, please refer to your member handbook.
If you have questions about referrals and when you need one, call the Customer Care Center at 800-782-0095 (TTY 711), Monday through Friday from 8 a.m. to 6 p.m.
Not a kid anymore? It may be time to change your primary care provider (PCP).
As an adult, you can choose to change from a provider who specializes in care for children or teens to a provider who focuses on treating adults. This includes providers for physical and behavioral health.
Start by asking your current PCP or mental health provider to recommend a provider who treats adults. You can also change your PCP or behavioral health provider with the Change Your PCP tool or by calling the Customer Care Center at 800-782-0095 (TTY 711).
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). Live chat with a representative and let them know if you want a copy of the Notice of Privacy Practices mailed to you. You can also download the Notice of Privacy Practices directly to your device or find it in your member handbook. New members will receive a copy of this notice once they have joined.