Conifer Health Solutions

1.800.459.2110 x 2247 | coniferhealth.com

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Frequently Asked Questions

Who is Conifer Health Solutions?

Conifer Health is a certified health solutions company and a national leader in personal health management and healthcare technology. With 30 years in the healthcare industry and on-the-ground experience in 135 markets nationwide, Conifer knows the ins and outs of local health systems, physician groups, employers and unions. Conifer helps members navigate the healthcare system and provide the tools for them to adopt healthy behaviors through collaboration and education. The Utilization Management provisions of the Trust’s Plan are administered by Conifer, our Utilization Management Vendor. The staff at Conifer are Physicians and Registered Nurses who monitor the use of your health care benefits to ensure that you and your family:

 

  1. Receive the best medical care possible in the most appropriate health care setting;
  2. Avoid unnecessary surgery and excess hospital days; and
  3. Receive answers to questions you have regarding medical care.

Components of the Utilization Management program include:

 

  1. Pre-certification of all hospital admissions,
  2. Continued Stay Review of all hospitalizations;
  3. Pre-certification of all Outpatient surgeries and the following: Residential Treatment Facility for Mental Health and Substance Abuse (considered inpatient); Birthing Centers; Clinical Trial Patient Cost Coverage; Intensive Outpatient Services for Mental Health and Substance Abuse, Durable Medical Equipment over $1,500 per Calendar Year; Home Health Care; Hospice Care; Skilled Nursing Facility, and Surgical treatment of morbid obesity;
  4. Case management of potentially catastrophic cases;
  5. Disease Management.

Pre-certification, continued stay review, and outpatient pre-notification decisions are based on the medical policy guidelines of the Utilization Management Vendor. Otherwise, all Medical Necessity reviews will be performed by the Claims Administrator utilizing CareFirst BlueCross BlueShield and other applicable medical policies.

There are only certain times when you can enroll in benefits or make changes – when you’re first hired, during open enrollment, or after a qualifying life event. So what exactly is a qualifying life event? Certain changes in your personal life qualify as an official change in status according to the IRS, which means that you can modify your benefit selections between open enrollment periods. Examples include changes in family status such as getting married, having a baby, or a change in child custody. In addition, a common qualifying life event is a change in employment status, such as a termination of employment or a change in employment status. Typically, you have 30 days from the date of the event to make changes to your benefits.
Conifer Health’s goal is to help you find the best care possible within the options offered through your employer’s health plan. In addition, your personal health nurse will advocate for your health needs by working with you and your family members to identify community resources to further support your goals for healthy living.
Conifer Health serves many thousands of health plan members through its unique and holistic approach to personal health management. Throughout the personal health management program, your medical information is handled in a confidential and professional manner and will not be shared with your employer or anyone else without your consent. Our clinical team comprises full-time nurses who are credentialed and certified through state laws and professional groups, and our clinical guidelines are regularly reviewed by nationally-recognized practicing physicians. In addition, the Conifer Health Personal Health Management operation is accredited by a national quality organization.
An experienced nurse employed by Conifer Health reviews your health information and determines if you, or a dependent, could benefit from Personal Health Management support. If you qualify for the program, a nurse will call you to provide you with key information about the program and to discuss your healthcare needs. If you choose to enroll in the program, the nurse becomes your personal health nurse and serves as your healthcare advocate — helping you live a healthier life through personalized, convenient support. Additionally, if you feel that you qualify for the Personal Health Management program, you may contact your personal health nurse directly.
Personal Health Management through Conifer Health, is a free, confidential program that empowers you to become informed and proactive about leading a healthier life. Whether you are chronically ill, suffering from complex medical conditions or experiencing an acute illness, navigating the evolving healthcare system can be challenging. The Personal Health Management program offers one-on-one support by collaborating with you and your healthcare providers to develop your customized care plan. Our goal is to provide the peace of mind you need to start focusing on the right things, like improving and maintaining your health.

Pre-authorization or pre-certification is a process completed by Conifer Health Solutions, the Trust’s Utilization Management Vendor. Certain services covered by the Plan require this process (like Hospitalizations, Continued stays at an Inpatient Facility, and some outpatient services).

If your Physician recommends that you or a covered family member be hospitalized, you must contact the Utilization Management Vendor for assistance with the certification process. Hospitalizations out of the country or when this Plan is the secondary payer do not require pre-certification. All other hospitalizations require pre-certification prior to an elective or planned hospitalization or the next business day after an urgent or emergency admission. To obtain pre-certification for an admission, call Conifer Value-Based Care at 877-687-9527.

When you call, have your Medical ID number, Employer name, patient name, home phone number, physician name and phone number ready.

Notification may be initiated by you, a family member, your Physician, or representative from the hospital. The Utilization Management Vendor will review your Physician’s recommendations based on the medical information supplied and accepted standards and criteria for hospital admission. In most cases, the Utilization Management Vendor will notify you, your doctor, and the hospital of your certification approval within 24 hours. (For hospitalizations, the hospital will be advised of the number of approved days when Conifer provides certification approval).

Conifer’s licensed Utilization Management Nurses review all requests first. If needed, they refer to doctors at the Medical Review Institute of America for additional review.

We recommend your doctor submit pre-certification requests two (2) weeks before a scheduled medical service. Please follow-up with your doctor to make sure they submit the requested medical information promptly after submitting the pre-certification request.

You will want to make sure your doctor submits as much detail as possible. Requests that lack detail may require additional review by a Medical Director, which can add time to processing your pre-certification request.

Urgent/Emergency pre-certification requests are typically processed within 72 hours. Your doctor should notify Conifer as soon as possible if you are admitted.

You and your doctor will get a letter with the reasons and suggestions for alternative treatments. In some situations, a Conifer Nurse may also reach out to assist you.

Yes. The denial letter will explain how to file an appeal. You can also contact your Personal Health Nurse to help you through the process.

Check with your health plan before treatment to avoid surprises. You can contact CareFirst Administrators (at the number on the back of your ID card) to verify if a service requires pre-certification. You can contact Conifer at 877.687.9527 to check on the status of your pre-certification.

Typically, the following services require pre-certification, but please review your Summary Plan Document for details, or contact CareFirst Administrators at the number on the back of your medical ID card.

  • Inpatient Hospital Admissions
  • Residential Treatment Facility
  • Birthing Centers
  • Clinical Trial Patient Cost Coverage
  • Durable Medical Equipment (DME) (in excess of $1500 per Calendar Year)
  • Home Health Care
  • Intensive Outpatient Services for Mental Health and Substance Use Disorders
  • Hospice Care
  • Outpatient Surgery in an Ambulatory Surgical Facility or other Outpatient Hospital Facility Setting (This does not apply to Cataract Surgery, Colonoscopy, Vein Surgery/Vein Procedures)
  • Skilled Nursing Facility
  • Surgical Treatment of Morbid Obesity
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