The purpose of medical policy is to provide guidelines for determining coverage criteria for specific procedures, equipment and services. The Introduction section of this manual includes information about:
- Approval process
- Research sources
- Definition of medical necessity
- Technology assessment process
- Definition of investigational services
Selecting of technologies for policy development
View commercial medical policies
View Medicare Advantage medical policies
Updates to our medical policies are communicated in The Bulletin. Reminders about changes that require 90-day notification are then announced in The Connection.
Reimbursement policy documents our payment policy and correct coding for medical and surgical services and supplies. It is used to provide consistent and predictable claims payment through the systematic application of our member contracts, provider agreements and medical policies.
Reimbursement policy updates are published in The Bulletin. Reminders about changes that require 90-day notification are then announced in The Connection.
Dental policies have been developed through consideration of government approval status, dental necessity, generally accepted standards of dental practice and review of dental literature.
We publish updates to dental reimbursement policies in our newsletter, The Connection.
Medication policies are based upon research of scientific literature, government approval status, and evidence-based treatment guidelines supporting clinical best practice/standards of care.
Clinical Practice Guidelines (CPGs) are systematically developed statements on medical practices that help physicians and other practitioners make decisions about appropriate health care for specific medical conditions.