Medical Policies and Clinical UM Guidelines
There are several factors that impact whether a service or procedure is covered under a member’s beneﬁt plan. Medical policies and clinical utilization management (UM) guidelines are two resources that help us determine if a procedure is medically necessary. These guidelines are available to you as a reference when interpreting claim decisions.
Blue Cross and Blue Shield of North Carolina (Blue Cross NC) has contracted with Amerigroup Partnership Plan, LLC for certain administrative functions including medical management.
Medical Policies are used by all plans and lines of business unless Federal or State law — as well as contract language, including definitions and specific contract provisions or exclusions — take precedence over a medical policy. Those provisions will be considered first in determining eligibility for coverage before the medical policy is used to determine medical necessity.
Clinical UM Guidelines
The Clinical UM Guidelines published on this website are not always used by all plans or lines of business. Clinical UM Guidelines are available for adoption to review the medical necessity of services related to the guideline when the plan performs a utilization review for the subject. Because practice patterns, claims systems and benefit designs vary, a local plan may choose whether to adopt a particular clinical UM guideline.
Health plans or lines of business that determine there is not a need to adopt a clinical UM guideline may instead use the guideline for educational purposes or to review the medical necessity of services for any provider who has been notified that his or her claims will be reviewed due to billing practices or claims that are inconsistent with other providers.
To determine which clinical UM guidelines have been adopted by your plan, or to determine if there are applicable other criteria, you can use the guideline adoption link:
In addition to the documents we develop and maintain for coverage decisions, we may adopt criteria developed and maintained by other organizations. Note that where we have developed a medical policy that addresses a service also described in one of these other sets of criteria, the plan’s medical policy supersedes.
MCG Care Guidelines
The MCG Care Guidelines are licensed and used to guide utilization management decisions for some health plans. This may include but is not limited to decisions involving prior authorization, inpatient review, level of care, discharge planning and retrospective review. MCG Care Guidelines are licensed and include:
- Inpatient & Surgical Care
- General Recovery Care
- Recovery Facility Care
- Behavioral Health Care
Customizations to MCG Care Guidelines
This document provides a summary of customizations to the MCG Care Guidelines 25th Edition (Publish date August 19, 2021).
Customizations to MCG Care Guidelines 25th Edition
This document provides a summary of customizations to the MCG Care Guidelines 26th Edition (Publish date December 9, 2022).
Customizations to MCG Care Guidelines 26th Edition
This document provides a summary of customizations to the MCG Care Guidelines 27th Edition (Publish date March 1, 2023).
Customizations to MCG Care Guidelines 27th Edition
Carelon Medical Benefits Management
Our health plans may use guidelines developed by Carelon Medical Benefits Management, Inc. to perform utilization management services for some procedures and certain members.
Carelon Medical Benefits Management guidelines applicable to plan programs are maintained by Carelon Medical Benefits Management. Updates to these guidelines can be found on their website.
Carelon Medical Benefits Management is an independent company providing utilization management services for Healthy Blue providers on behalf of Blue Cross and Blue Shield of North Carolina.
Publish date: the date a medical policy or clinical UM guideline was made available on our public websites
Last review date: the date a medical policy or clinical UM guideline was reviewed and approved
Note that while a publish date is enterprise-wide, the implementation date may differ depending on notification requirements. Please refer to the plan Provider Newsletter for more information relating to implementation dates.
To see a list of all Medical Policies and Clinical UM Guidelines, visit our Utilization Management Clinical Criteria List – this document lists the North Carolina Healthy Blue utilization management criteria that has been adopted .