|Utilization Management Guidelines (UMGs)|
The information below defines BlueCross BlueShield of Tennessee’s decision-making process for coverage of a service:
Member's Benefit Plan/Evidence of Coverage (EOC)
The member’s benefit plan (i.e., Evidence of Coverage [EOC]) is the first tool in the clinical decision process. If the service is provided within the EOC, 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 related medical appropriateness criteria for determining medical necessity.
MCG Care Guidelines and Utilization Management Guidelines (UMGs)
The UMGs are the third tool in the clinical decision process. If the EOC does not exclude the service, and a medical policy does not address the service, then the UMG should be applied to the request for the service.
- Ensure appropriate routing, tracking, and resolution of a Utilization Management Guideline appeal
- Establish a standard process for responding to Utilization Management Guideline appeals
- Give providers a standardized process to pursue when they disagree with a Utilization Management Guideline
- Provide accurate tracking of a Utilization Management Guideline appeal
What is a Utilization Management Guideline Appeal?
- A formal notice from a network provider stating their dissatisfaction with a Utilization Management Guideline
Information Required from a Provider
- Full-text copies of published, peer-reviewed, evidence-based research studies regarding the guideline in question that supports the provider’s position
Utilization Management Guideline Appeals Process
- Provider submits a written request for an appeal of a Utilization Management Guideline, along with copies of 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 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
Last Review Date: 9/3/2015