Utilization Management Guidelines (UMGs)

Appeals Process

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

Medical Policy

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



What is a Utilization Management Guideline Appeal?

Information Required from a Provider

Utilization Management Guideline Appeals Process

How to Submit a Utilization Management Guideline Appeal Request

Tennessee providers submit a written request with supporting documentation to:

Provider Appeals Coordinator
Provider Networks & Contracting Division
BlueCross BlueShield of Tennessee
1 Cameron Hill Circle
Suite 0039
Chattanooga, TN 37402


Last Review Date: 2/13/2019

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