MMCG Appeals Process

Modified Milliman Care Guidelines

Appeals Process

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 Milliman Care Guidelines.

Purpose	Modified Milliman Care Guideline Apppeals Process
What is a Modified Milliman Care Guideline Appeal?	How to Submit a Modified Milliman Care Guideline Appeal Request
Information Required from a Provider

Purpose

Ensures appropriate routing, tracking, and resolution of Modified Milliman Care Guideline appeals

Establishes a standard process for responding to Modified Milliman Care Guideline appeals

Gives providers a standardized process to pursue when they disagree with a Modified Milliman Care Guideline

Provides accurate tracking of appeals for reporting

What is a Modified Milliman Care Guideline Appeal?

A formal notice from a network provider stating his/her disagreement with any modification made to a Milliman Care Guideline

Appropriate appeals would include questioning the Goal Length of Stay (GLOS) assigned to a Modified Milliman Care Guideline or the Clinical Indications of a Modified Milliman Care 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 Milliman Care Guideline Appeals Process

Provider submits a written request for an appeal of a Modified Milliman Care 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 Milliman Care 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

* These guideline(s) have been revised from the Milliman USA Milliman Care Guidelines. The portions of the guideline(s) which have been revised are identified through the use of [insert: italic, boldface, underlined, etc. as appropriate] text, and Milliman USA has neither reviewed nor approved the modified material. Any statement to the contrary or association of the modified material with Milliman USA is strictly prohibited. This document has been classified as public information.

The above information only contains the modified portion of the Milliman Care Guideline. If you wish to view the complete Milliman Care Guideline, please contact Milliman USA.