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

Member Contract

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

Medical Policy

Medical Policy stipulates if the service requested is considered Medically Necessary, Cosmetic, not Medically Necessary, or Investigational.

Blue Cross BlueShield of Tennessee Utilization Management Guidelines

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

Purpose

• Ensures appropriate routing, tracking, and resolution of Utilization Management Guideline appeals
• Establishes a standard process for responding to Modified Utilization Management Guideline appeals
• Gives providers a standardized process to pursue when they disagree with a Modified Utilization Management Guideline
• Provides accurate tracking of appeals for reporting

What is a Modified Utilization Management Guideline Appeal?

• A formal notice from a network provider stating his/her disagreement with any modification made to a Utilization Management Guideline
• Appropriate appeals would include questioning the goal length of stay assigned to a Modified Utilization Management Guideline or the Clinical Indications of a Modified Utilization Management Guideline

Information Required from a Provider

• Published, evidence-based literature in support of the provider’s appeal (e.g., guidelines of nationally recognized organizations or well-designed clinical studies)

Modified Utilization Management Guideline Appeals Process

• Provider submits a written request for an appeal of a Modified Utilization Management Guideline, along with any supporting information to the Provider Appeals department
• The Provider Appeals department reviews the appeal and supporting information, and makes a recommendation to the Provider Appeals Committee
• 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 Modified Utilization Management Guideline Appeal Request

Network providers can submit a written request with supporting documentation to:

Provider Appeals Coordinator
Provider Networks & Contracting Division
BlueCross BlueShield of Tennessee
801 Pine Street
Chattanooga, TN 37402