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How Are Medical Necessity Decisions Made?

We want to ensure that all physicians are aware of the criteria and guidelines utilized by Blue Cross and Blue Shield of North Carolina (BCBSNC) to make medical necessity decisions for membership enrolled in our commercial products. In these decisions we are guided by the Milliman Care Guidelines and BCBSNC corporate medical policy.

In April of 2010, the updated 14th edition of the Milliman Care Guidelines was implemented. This edition contains many enhancements including addition of benchmarks and data tables, re-titling and reorganization of Care Management tools, and additional product-specific features such as new guidelines.

Our licensed nurses use Milliman Care Guidelines to authorize coverage for inpatient services, home care and rehabilitation services. Practitioners can obtain a copy of a specific Milliman Care Guideline or a BCBSNC medical policy by calling our Member Health Partnership Operations department at 1-800-672-7897, ext. 57078. Our medical policies are also available through our Web site at bcbsnc.com via the "Provider" portal.

If a nurse cannot approve a service, a BCBSNC medical director (who is licensed in North Carolina) will review the case and may approve or deny coverage based on Milliman Care Guidelines or BCBSNC medical policy, along with clinical judgment. Only a medical director can deny coverage for a service based on medical necessity. We encourage you to take part in a "peer-to-peer" consultation regarding a case before or after a determination, because a discussion between physicians can help clarify a situation and affect the determination. A BCBSNC medical director is always available during regular business hours and can be reached by calling 1-800-672-7897, ext. 51019.