BCBST Medical Policy Appeals Process

BCBST Medical Policy Appeals Process

The information below defines BlueCross BlueShield of Tennessee's decision-making process for coverage of a service:

Definitions

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

Purpose

  • Ensure appropriate routing, tracking, and resolution of medical policy appeals
  • Establish a standard process for responding to medical policy appeals
  • Give providers a standardized process to pursue when they disagree with a medical policy
  • Provide accurate tracking of medical policy appeals for reporting

 

What is a Medical Policy Appeal?

  • A formal notice from a network provider stating their dissatisfaction with any medical policy determination
  • The dissatisfaction could be questioning the investigational status of a medical policy or the medical appropriateness of a medical policy

Information Required from a Provider

  • Published, peer-reviewed, evidence-based research studies regarding the technology or procedure in question

 

Medical Policy Appeals Process

  • Provider submits a written request for an appeal of a medical policy, along with any supporting information to the Provider Appeals Department
  • Provider Appeals Coordinator sends the request to the Division Representative for Medical Policy Research & Development
  • Medical Policy Research & Development reviews the appeal and supporting information
  • The appeal decision is returned to the Provider Appeals Department with a detailed response for the provider
  • A written response is sent via registered mail to the network provider

 

How to Submit a Medical Policy Appeal Request

  • Network providers submit a written request & supporting documentation to:

    Provider Appeals Coordinator Provider Networks and Contracting Division
    BlueCross BlueShield of Tennessee
    1 Cameron Hill Circle
    Chattanooga, TN 37402