Medical Policies

Medical policy consists of medical guidelines, including diagnostic imaging management policies, reimbursement guidelines, evidence based guidelines and administrative guidelines.

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Medical Guidelines Reimbursement Guidelines Evidence Based Guidelines Administrative Guidelines
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Diagnostic Imaging Management Policies      

Medical Guidelines

These guidelines detail when certain medical services are considered medically necessary by BCBSNC, and whether or not they are considered investigational by BCBSNC. (For more information concerning medical necessity and investigational criteria, please see these specific policies.) Our medical guidelines are written to cover a given condition for the majority of people. Each individual's unique, clinical circumstances may be considered in light of current scientific literature. Medical guidelines are based on constantly changing medical science, so we review and update our policies periodically.

Diagnostic Imaging Management Policies

As part of the BCBSNC diagnostic imaging management program, CT/CTA, MRI/MRA and PET scans, as well as nuclear cardiology services, may require prior plan approval when received on a nonemergency outpatient basis, such as in a doctor's office, the outpatient department of a hospital or at a freestanding imaging center (for dates of service on or after February 15, 2007)1. For detailed information regarding which services are subject to the diagnostic imaging management guidelines, for which members and under what circumstances, please see the specific policies.

The diagnostic imaging management policies promote the most appropriate use of outpatient diagnostic imaging procedures, the proper sequence of studies, and the most efficient use of members' benefits.

Reimbursement Guidelines for Providers

These guidelines provide claims payment editing logic for CPT, HCPCS and ICD-9-CM coding. Reimbursement guidelines are developed by clinical staff and include yearly coding updates, periodic reviews of specialty areas based on input from specialty societies and physician committees and updated logic based on current coding conventions.

Benefits and eligibility are determined before medical guidelines and reimbursement guidelines are applied. Therefore, medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the group contract and the subscriber certificate that is in effect at the time services are rendered.

Evidence Based Guidelines

Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence to make decisions concerning the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

Evidenced Based Guidelines are a tool for closing the gap between what physicians actually do and what scientific evidence supports. They bring together the best external evidence and other knowledge necessary for decision-making about specific health problems.

The major benefit of evidence-based guidelines is to improve the quality of care that patients receive by offering explicit recommendations about how to proceed and provide authoritative recommendations that reassure practitioners about the appropriateness of their treatment policies. Guidelines based on a critical appraisal of the scientific evidence clarify which interventions are based on proven benefit and document the quality of the supporting data. They also alert clinicians to those interventions that are unsupported by good science, reinforce the importance and methods of critical appraisal, and call attention to those practices that are ineffective, dangerous and wasteful.

Blue Cross Blue Shield of North Carolina (BCBSNC) has based the guidelines on evidence based medicine as well as input from specialty-matched physicians. BCBSNC has considered effectiveness, tolerability, harm, quality of life, health-service delivery issues, and cost. We do, however, recognize that not every guideline is appropriate for every patient. Therefore, we would expect the physician to consider the best external evidence and other knowledge necessary for decision-making about specific health problems for a specific patient.

While medical policy coverage guidelines generally are enforced in BCBSNC claims payment systems, evidence based guidelines are not. BCBSNC provides this information or guidance to clinicians faced with decisions regarding best use of medical technologies and procedures. BCBSNC reserves the right to evaluate evidence based practice as one component of healthcare quality improvement efforts.

Administrative Guidelines for Providers

These guidelines provide general information regarding the definition of Medical Necessary and Investigational/Experimental services as defined by Blue Cross Blue Shield of North Carolina (BCBSNC). Additionally, a policy for participation in clinical trials is available as an administrative guideline.

 

1 Prior review/prior approval is not required when services are performed in an emergency room, hospital (related to an inpatient stay), urgent care center or ambulatory surgical center.