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Medical Policies

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

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Medical Guidelines Reimbursement 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 center1. 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.

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.

Supporting Websites

In certain markets, Blue Cross and Blue Shield of North Carolina, delegates the Utilization Management for PRIOR REVIEW and CERTIFICATION of specific services or benefits to other companies not associated with BCBSNC. Please see below for a list of these companies:

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.