Blue cross medical policy statement
 

Medical Policy and Utilization Management Requirements

Timeliness

To ensure timely processing and assist us in meeting compliance with State and Federal guidelines, please submit pre-certification / pre-authorization requests at least 10 business days prior to any elective services being rendered.

For expedited requests, Blue Cross Blue Shield of Minnesota adheres to federal and state requirements for decision making time frames. Blue Cross uses the following definitions to determine if a request is expedited:

For Commercial Plans

  • Requires immediate action to prevent a serious deterioration of a member’s health that results from an unforeseen illness or an injury, or
  • Could jeopardize the ability of the individual to regain maximum function based upon a prudent layperson’s judgment, or
  • In the opinion of the treating physician, would subject the individual to severe pain that cannot be adequately managed without the treatment being requested. An urgent condition is a situation that has the potential to become an emergency in the absence of treatment.

For Minnesota Government Programs

  • The attending health care professional believes that an expedited determination is warranted when the standard decision timeframe may jeopardize the member’s health or ability to regain maximum functioning.
  • An expedited determination is completed as the enrollee's medical condition requires, but no later than 72 hours from the initial request.

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Product Application: These policies apply generally to all Blue Cross and Blue Plus fully insured plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the medical policies. Medicaid products may have additional policies and prior authorization requirements, as well as some self-insured plans. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law.

Medical Policy

Drugs, devices, diagnostic procedures, medical treatments or procedures are not covered by Blue Cross until final review and approval by the Blue Cross Coverage Committee. This Committee reviews recommendations from the Medical and Behavioral Health Policy Committee, the Pharmacy Committee, and the Coding and Reimbursement Committee. All claims are subject to post-service review for medical necessity and benefits.

This requirement of Committee review is a precondition of Blue Cross coverage and:

  • Applies in addition to all other conditions and terms stated in Blue Cross contracts and stated herein; and
  • Applies to medications and medical devices when administered in any manner that is approved by the U. S. Food and Drug Administration (FDA); and
  • Applies to approved medications legally prescribed and medical devices legally used when administered in any manner that is not mentioned in the labeling approved by the FDA (referred to as an "off-label" use). Use of a medication or medical device for an indication, dosage form, dose regimen, population, or other use parameter not mentioned in the approved labeling is considered to be an "off-label" use.

Blue Cross reserves the right to revise, update and/or add to these policies at any time without notice. If members or providers have questions about a policy, they are welcome to contact Blue Cross.

Utilization Management Pre-Certification / Pre-Authorization Requirements

  • Services and/or Supplies: A current list of services and/or supplies for which pre-certification / pre-authorization is required is located at providers.bluecrossmn.com. The purpose of pre-certification / pre-authorization is to review services prior to being rendered to determine if the services are contractually eligible and medically necessary. Medical policy criteria and member contract language is used to assist in determining if benefits are available for the requested service. Certification / Authorization for a service, device or drug does not in itself guarantee coverage, but notifies you that as described, the service, device or drug meets the criteria for medical necessity and appropriateness. Payment for services and/or supplies Blue Cross approves in advance is based on the following requirements: if the policy is in force the date the member receives care, premiums have been paid, lifetime or benefit maximums have not been exceeded, the condition is not subject to a preexisting condition limitation period, and the procedure that is authorized is the service and/or supply that is billed by the provider. Deductibles, coinsurance, allowed amount and co-payments will apply.
  • Inpatient Pre-Service Admission Requirements: The member’s identification card has a number to call for pre-certification / pre-authorization for inpatient admissions.

Receipt of benefits is subject to all terms and conditions of the member's plan documents. Members and providers should consult their contract, certificate of coverage, or summary plan description (SPD), as applicable, to review the provisions relating to a specific coverage determination, including exclusions and limitations. If there is a conflict between the information above and the contract or plan documents, the contract or plan documents govern.

These policies in no way imply that members should not receive specific services based on the recommendation of the provider. These policies govern coverage and not clinical practices. Providers are responsible for medical advice and treatment of patients. Members with specific health care needs should consult an appropriate health care professional.

Members and providers have rights to appeal coverage decisions. These rights are spelled out in member or provider plan documents. If members have questions about appeal rights, they should contact customer service at the number located on the back of the member ID card. If providers have questions about appeal rights, contact provider services at (651) 662-5200 or toll free at 1-800-262-0820.

This information is not an offer of coverage, solicitation of coverage, summary of coverage or guarantee of coverage. All products and coverage guidelines are subject to applicable laws and regulations. Member or provider coverage is contingent on all the applicable terms, conditions, limitations and exclusions of member or provider plan documents.