Policies, Manuals and Guides

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.

Provider Manual

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  Healthy Blue Provider Manual
or  Healthy Blue Care Together Provider Manual.

View or download the Quick Reference Guide.

Medical Policies and Clinical UM Guidelines

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.

Providers, improve your prior authorization and claims submission process. Our new online Clinical Documentation Lookup Tool (CDLT) gives real-time access to the highly recommended medical documents needed with submission.

Access the Clinical Documentation Lookup Tool

Medical Policies and Clinical UM Guidelines 

Pharmacy Criteria

For pharmacy prior authorization criteria, please see documents posted at the following link: hhttps://medicaid.ncdhhs.gov/providers/program-specific-clinical-coverage-policies

Interested in becoming a provider in the Healthy Blue network?

We look forward to working with you to provide quality services to our members.