|Modified Utilization Management Guidelines|
The information below defines BlueCross BlueShield of Tennessee’s decision-making process for coverage of a service:
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.
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 and 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.
- Ensure appropriate routing, tracking, and resolution of Utilization Management Guideline appeals
- Establish a standard process for responding to Modified Utilization Management Guideline appeal
- Give providers a standardized process to pursue when they disagree with a Modified Utilization Management Guideline appeal
- Provide accurate tracking of appeals for reporting
What is a Modified Utilization Management Guideline Appeal?
- A formal notice from a network provider stating their dissatisfaction with any modification made to a Utilization Management Guideline
- The dissatisfaction could be 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
- 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 Modified Utilization Management Guideline Appeal Request
Network providers submit a written request with supporting documentation to:
Provider Appeals Coordinator
Provider Networks & Contracting Division
BlueCross BlueShield of Tennessee
1 Cameron Hill Circle
Chattanooga, TN 37402