Care management and medical necessity

We want to ensure that all physicians are aware of the criteria and guidelines utilized by Blue Cross NC to make medical necessity decisions for membership enrolled in our commercial products. In these decisions we are guided by evidence-based care guidelines from MCG Health and Blue Cross NC corporate medical policy.

Our licensed nurses use MCG to authorize coverage for inpatient services, home care and rehabilitation services. MCG are updated annually and practitioners can obtain a copy of a specific MCG or a Blue Cross NC medical policy by calling our Care Management department at 800-672-7897, ext. 57078. Our medical policies are also available through our website at Blue Cross NC.com via the "Provider" portal. If a nurse cannot approve a service, a Blue Cross NC medical director (who is licensed in North Carolina) will review the case and may approve or deny coverage based on MCG or Blue Cross NC medical policy, along with clinical judgment. Only a medical director can deny coverage for a service based on medical necessity. We encourage you to take part in a "peer-to-peer" consultation regarding a case before or after a determination, because a discussion between physicians can help clarify a situation and affect the determination. A Blue Cross NC medical director is always available during regular business hours and can be reached by calling 800-672-7897, ext. 51019.

Did you know that there are standards in place that protect health care consumers? The National Committee for Quality Assurance (NCQA), a not-for-profit organization that accredits Blue Cross NC, has developed standards that do just that. NCQA and Blue Cross NC want you to know that:

• Any decisions made by Blue Cross NC about coverage for care or service are based on your patient's benefit plan, Blue Cross NC medical policy and information from the doctor about the patient's medical condition.
• The Blue Cross NC doctors and nurses who review your or your patient's requests for service or coverage are not rewarded for denying or limiting coverage.
• Financial incentives for UM decision makers do not encourage decisions that result in underutilization.
• At Blue Cross NC, we are committed to making appropriate coverage decisions about our members' health care that meet the terms of their health benefit plan while meeting their medical needs.

Blue Cross NC medical directors are available to discuss clinical problems and benefit issues with network providers particularly where there are issues that complicate the management of the patient's condition.

• A peer to peer review is a clinical discussion between a requesting physician and a Blue Cross NC medical director.
• If you have questions about a certification request, you may request to speak directly to a medical director by calling  800-672-7897, ext. 51019.
• A peer to peer review may also be requested by a Blue Cross NC medical director in order to obtain more clinical information from an attending physician before making a final determination.
• The purpose of the peer to peer discussion is to give the requesting physicians an opportunity to discuss the clinical details of a requested service.