Description

The Choosing Wisely® and Practicing WiselyTM initiatives evaluate usage of health care services with a goal of reducing excessive tests and procedures that result in unnecessary medical spend. Subject matter experts and specialty societies provide recommendations for preventing overuse of health care services having a potentially negative impact on both the quality and/or cost of health care.

Policy

Blue Cross North Carolina (Blue Cross NC) does not reimburse for overuse of services according to the guidelines in this policy. 

Rationale

Based on Choosing Wisely® and Practicing WiselyTM guidance, Blue Cross NC will limit reimbursement for services deemed overuse.

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross NC web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Related policy

Bundling Guidelines

References

https://choosingwisely.org

https://motivepw.com

https://www.ncqa.org/hedis/measures/use-of-imaging-studies-for-low-back-pain

History

04/18/2023 New policy developed. MD Approval. Notification on 4/18/2023 for effective date 6/18/2023. (eel)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.