Medical Policy and Utilization Management Requirements
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
For Minnesota Government Programs
By clicking on the "I accept" button below, I acknowledge that I understand and accept the following:
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.
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:
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
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 o