The information below defines BlueCross BlueShield of Tennessee's decision-making process for coverage of a service:
Member Contract – The member’s contract is the first tool in the clinical decision process. If the service is provided within the contract, then it may require evaluation for medical appropriateness
Medical Policy – The medical policy is the second tool in the clinical decision process. The Medical Policy Manual will provide policy statements and medical appropriateness criteria to determine medical necessity
MCG Care Guidelines, including, Modified Utilization Management Guidelines – The UM criteria is the third tool in the clinical decision process. If the contract addresses the service, but Medical Policy does not, then the UM guidelines should be applied to the request for the service
What is a Medical Policy Appeal?
Information Required from a Provider
Medical Policy Appeals Process
How to Submit a Medical Policy Appeal Request