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 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.
Medical Policies and Clinical UM Guidelines
- Utilization Management Clinical Criteria
- In-home Respite In Lieu of Service UM Guideline
- Environmental Modification In Lieu of Service UM Guideline
- Community Reintegration In Lieu of Service UM Guideline
- Enhanced Personal Care Services In Lieu of Service UM Guideline
- Enhanced Private Duty In Lieu of Service UM Guideline
- 2023 Clinical Practice Guidelines
- NC Clinical Coverage Policies – this document provides links to the North Carolina Medicaid Division of Health Benefits Clinical Coverage Policies
- Utilization Management Clinical Criteria List – this document lists the North Carolina Healthy Blue utilization management criteria that has been adopted
- Behavioral Health Urgent Care-In Lieu of Service
- Institute of Mental Disease (IMD)-In Lieu of Service
- HEDIS Desktop Reference Guide 2022
- August 2022 Clinical Utilization Management Guidelines
- Clinical Utilization Management Criteria February 2023
Pharmacy Criteria
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