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

Definitions

Member Contract - The member's contract tells what services will be covered by the insurance company.

Medical Policy - Medical Policy tells if the service requested is considered medically necessary, cosmetic, not medically necessary, or investigational.

BCBST Utilization Management - Utilization Management (UM) Criteria gives clinically related information to assist with decision-making. BlueCross BlueShield of Tennessee uses Milliman Care Guidelines® and / or BlueCross BlueShield of Tennessee Modified Milliman Care Guidelines.

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 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 the Medical Policy Research & Development Department
• Medical Policy Research & Development Department reviews the appeal and supporting information
• The appeal decision is returned to the Provider Appeals Department with a detailed response for the provider
• The Provider Appeals Committee, consisting of key Senior and Executive Management from various BlueCross BlueShield of Tennessee departments, reviews the information for a final decision
• 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
801 Pine Street
Chattanooga, TN 37402