Patient care

The guidelines, programs and tools in this section have been designed and/or endorsed to assist providers in delivering the best possible care to their patients.

Clinical practice guidelines

In order to help improve clinical outcomes, various clinical organizations have developed the evidence-based guidelines below. The guidelines are not intended to replace clinical judgment.

If you would like hard copies of any guidelines, please contact your Provider Relations representative.

Behavioral health clinical practice guidelines

WellSense requires primary care providers to offer Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services, which should include comprehensive health screening, developmental history, an unclothed physical exam, appropriate immunizations, laboratory tests and health education to all WellSense members, 21 years of age and younger, per the American Academy of Pediatrics Bright Futures periodicity schedule.

Additional Resources

Bright Futures (The selected guideline for NH Medicaid plans.)

When a member requests a primary or specialty care appointment, providers are required to follow the WellSense Access to Care Guidelines regarding appointment availability wait times. Here are the standards:

After-Hours Services Provide one of the following:  
  • 24-hour answering service with option to page the physician, OR
  • Advice nurse with access to the PCP or on-call physician  
Emergency and Psychiatric Services
  • Immediately upon entrance to delivery site, including network and out-of-network facilities
  • 24/7 services  
Primary Care Services
  • Routine, non-symptomatic: 30 days
  • Non-urgent, symptomatic: 10 days
  • Urgent: 28 hours  
Expectant Mothers
  • Non-symptomatic care: 30 days
  • Symptomatic care: 10 days
  • Urgent care: 48 hours
  • Initial prenatal visit: 21 days
  • Initial family planning visit: 10 days  
Newborn Visit
  • Within 14 calendar days of hospital discharge  
Outpatient Specialty Services Primary, specialty or approved community mental health provider:
  • Within 2 calendar days following discharge  
Transitional Care Primary, specialty or approved community mental health provider: ·  Within 2 calendar days following discharge    
Transitional Home Care Within 2 calendar days following discharge ·        

Well Sense knows that a fragmented approach to members’ health needs does not allow for the best level of care. That’s why WellSense’s Care Management Model integrates physical, social, behavioral health services, pharmacy management, and wellness programs, enabling us to fully respond to our member’s needs.

This integrative and collaborative approach includes assessing the member’s overall health status, facilitating coverage for medically necessary services, social and community-based services, and advocating for the member as he or she navigates the healthcare system.

WellSense’s priority is to help members with all their health-related needs, including members with special health care needs who may have developmental delays and co-occurring disorders and members receiving services through waiver programs. The goal is for members to regain optimum health or improved functional capability. WellSense aims to proactively identify and engage our members, their families, and significant supports in a way that integrates care management with medical, social, environmental, behavioral health, medication management, wellness, and community support. We focus on what matters to members, the provider’s care and coordination of services, other Plan resources and departments (e.g., UM, Pharmacy, Member Services, and Provider Engagement). We maximize value through the most efficient use of available resources and technology, resulting in better health, better experience, and better health outcomes.

When members have a significant disability or disabling disease, the care management program helps them maintain an acceptable quality of life in a cost-effective manner, while offering the highest quality of care. Early identification of members and disabilities, disabling conditions, or frailty is essential to WellSense’s ability to conduct an assessment resulting in an individualized and comprehensive person-centered plan for the member.

Our clinical and/or non-clinical professionals use a multi-disciplinary approach, providing goal-oriented and culturally competent services to members. With an emphasis on prevention, self-management, and care coordination across providers and health settings, this approach ensures the provision of necessary services by a member’s primary care physician, licensed professionals, agencies, and care givers.

Care Management Services Offered

WellSense’s Care Management program consists of the following components:

  • Care coordination and care navigation for medical, behavioral health, and social needs
  • Non-emergency medical transportation
  • Wellness and prevention programs
  • Chronic care management programs
  • High-cost/high-risk member management programs
  • Management of members with Priority Population characteristics: Adults and children with special health care needs, including members with:
    • HIV/AIDS
    • A Serious Mental Illness (SMI)
    • A serious emotional disorder (SED)
    • Intellectual/developmental disability
    • Substance use disorder diagnosis (SUD)
    • Chronic pain
    • Members receiving services under HCBS waivers
    • Members identified as those with rising risk
    • Individuals with high unmet resource needs
    • Mothers of babies born with neonatal abstinence syndrome
    • Pregnant women with SUD
    • Intravenous drug users, including members who require long-term IV antibiotics and/or surgical treatment as a result of IV drug use
    • Individuals who have been in the ED for an overdose event in the last 12 months
    • Recently incarcerated individuals
    • Individuals who have a suicide attempt in the last 12 months.
  • Coordination and integration with social services and community care
  • Coordination of long term services and supports
If a member is identified for care management and agrees to participate, a Care Manager will notify you, the provider, by letter or telephone and work to coordinate your patient’s care. Contact your Provider Relations Consultant to find out what reports are available about your patients. If you would like to refer a patient to our care management program, please contact our care management department at 855-833-8119, or complete and submit the referral form. Our care management staff will evaluate the member and enroll him/her in the most appropriate program(s) based on condition, the severity of illness and individual needs.