Information about our clinical programs
March 6, 2020
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, go to |
|---|---|
| Health management programs Resources about case management, care management for chronic conditions, and referrals. |
Health Management Programs |
| Medical necessity We use Change Healthcare’s criteria as well as supplemental guidelines to determine medical necessity. |
InterQual® Criteria & SmartSheets
Coverage Criteria & Guidelines (for certain services that are not addressed by InterQual criteria or medical policies)
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| Medical policies Medical policies will help you to determine what we cover and why. |
Medical Policies |
| Member rights and responsibilities Information about access-to-care and member rights and responsibilities. |
See Member Rights and Responsibilities by logging in and going to Office Resources>Policies & Guidelines> Provider Manuals. |
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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