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2019 information about our clinical programs
February 28, 2019

Blue Cross is dedicated to developing and executing quality initiatives in partnership with our providers. We want you to know that the following information is available on our website.

Programs & guidelines To learn more, log on and select
Health management programs

Resources about case management, chronic condition management, and referrals.

Clinical Resources>Health Management Programs
Medical necessity

We use Change Healthcare’s criteria as well as supplemental guidelines to determine medical necessity.

Clinical Resources>Prior Authorization>InterQual Criteria & SmartSheets

Clinical Resources>Coverage Criteria & Guidelines

Medical policies

Medical policies will help you to determine what we cover and why.

Office Resources>Policies and Guidelines>Medical Policies
Member rights and responsibilities

Information about access-to-care and member rights and responsibilities.

Office Resources>Policies & Guidelines>Provider Manuals

See Member Rights and Responsibilities and Medicare Advantage Member Policies and Procedures in the appendix

About our utilization management standards

As part of our compliance with NCQA, we want providers to understand our standards for utilization management.

  • We encourage appropriate use and discourage over- and under-use of health care services.
  • We do not reward or offer financial incentives to utilization management staff to encourage decisions that result in under-utilization of care.  
  • We do not specifically reward practitioners or other individuals for issuing denials of coverage.
  • We do not incentivize or encourage barriers to care and service.
  • Utilization management decision-making is based only on appropriateness of care and service and existence of coverage.


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