Modified Utilization Management Guidelines

Appeals Process


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

Member's Contract

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.

Medical Policy

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.

 

Purpose

What is a Modified Utilization Management Guideline Appeal?

Information Required from a Provider

Modified Utilization Management Guideline Appeals Process

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

 

Last Review Date: 3/3/2014