We are committed to supporting you in providing quality care and services to Healthy Blue members. Here you will find information for assessing coverage options, guidelines for clinical utilization management (UM), practice policies and support for delivering benefits to our members.
Healthy Blue’s provider manual provides key administrative information including the quality improvement program, the UM program, quality standards for participation, claims appeals, and reimbursement and administration policies.
View or download the provider manual.
View or download the Quick Reference Guide.
Medical Policies address the medical necessity of new services or procedures and new applications of existing services or procedures. Clinical UM Guidelines focus on detailed selection criteria, lengths of stay goals, and location for generally accepted technologies or services.
For pharmacy prior authorization criteria, please see documents posted at the following link: https://medicaid.ncdhhs.gov/providers/clinical-coverage-policies/pharmacy-services-clinical-coverage-policies