Medical Policies and Clinical UM Guidelines
There are several factors that impact whether a service or procedure is covered under a member’s beneļ¬t 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
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:
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 24th Edition (publish date January 20, 2021).
Customizations to MCG Care Guidelines 24th Edition
AIM Specialty Health
Our health plans may use guidelines developed by AIM Specialty Health® (AIM) to perform utilization management services for some procedures and certain members. AIM guidelines that may be adopted for use include:
- Clinical Appropriateness Guidelines for Radiology (adult and pediatric)
- Clinical Appropriateness Guidelines for Sleep Disorder Management
- Musculoskeletal Clinical Appropriateness Guidelines: spine surgery, joint surgery and interventional pain management
- Level Of Care Guidelines for Musculoskeletal Surgery and Procedures
- Preoperative Admission Guidelines for Musculoskeletal Surgery and Procedures
- Cardiology Clinical Appropriateness Guidelines: advanced imaging of the heart, arterial ultrasound, percutaneous coronary intervention and diagnostic coronary angiography
- Radiation Oncology Clinical Appropriateness Guidelines: brachytherapy, intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS)
- Clinical Appropriateness Guidelines for Outpatient Rehabilitative and Habilitative Services
AIM guidelines applicable to plan programs are maintained by AIM Specialty Health. Updates to these guidelines can be found on their website.
By selecting the link to AIM below, you are now leaving our site and visiting a site created and/or maintained by AIM ("External Site"). Upon visiting, you are subject to the terms of use, privacy, copyright and security policies of the External Site. We provide this link solely for your information and convenience. We encourage you to review the privacy practices of the External Site. The information contained on the External Site should not be interpreted as medical advice or treatment provided by us.
AIM Guidelines
AIM Specialty Health is an independent company providing utilization management services for Healthy Blue providers on behalf of Blue Cross and Blue Shield of North Carolina.
IngenioRx
IngenioRx, Inc. is an independent company providing pharmacy benefit management services for Healthy Blue members 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 Full List page.