Medical policy consists of medical guidelines, including diagnostic imaging management policies, reimbursement guidelines and administrative guidelines.
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These guidelines detail when certain medical services are considered medically necessary by Blue Cross NC, and whether or not they are considered investigational by Blue Cross NC. (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 Blue Cross NC 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.
Medical Oncology Program
Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will be implementing a new Medical Oncology Program (Program) effective April 1, 2017. The new program is designed to promote optimal support for our members' cancer care needs, while simultaneously reducing the costs for managing one of the most complex, expensive and prevalent diseases members can encounter. The Program includes online access for oncologists, urologists, and hematologists to decision support tools for selecting cancer treatment regimens, which are consistent with current evidence and consensus guidelines. In addition, the Program includes Cancer Treatment Pathways (Pathways) based on medical evidence and best practices developed with leading cancer experts. Pathways offer support in identifying highly effective therapies that can be often more affordable for our members.
Pathway regimens are widely accepted as a key component to manage oncology quality and costs. More specific than guidelines, Pathway regimens identify treatments selected based on clinical effectiveness, favorable toxicity profiles, and cost. The Cancer Treatment Pathways are based on a detailed review of efficacy, toxicity and cost informed by a clinical library and include evidence drawn from:
- Peer-reviewed published literature,
- expert consensus statements and guidelines from professional organizations including the American Society of Clinical Oncology (ASCO), the American Society of Hematology (ASH), and The National Comprehensive Cancer Network (NCCN), as well as
- government agencies including the Food and Drug Administration (FDA) and the National Cancer Institute (NCI).
The Program will be administered by AIM Specialty Health® (AIM). Starting April 1, 2017, AIM will help to improve cancer care quality for eligible Blue Cross NC members, as well as manage the associated costs for certain complex tests and treatments, through promoting patient care that's appropriate, safe and affordable.
Reimbursement Guidelines for Providers
These guidelines provide claims payment editing logic for CPT, HCPCS and ICD-10-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 (Blue Cross NC). Additionally, a policy for participation in clinical trials is available as an administrative guideline.
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 Blue Cross NC. 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.