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.
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:
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:
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
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 applicable to plan programs are maintained by AIM Specialty Health. Updates to these guidelines can be found on their website.
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, 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.
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 .
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