Medical Policy Development and Application

Purpose of Policy Development

The primary objective of policy development is to ensure that members receive the most suitable care at the optimal time to effectively treat their medical conditions. Medical Policies are designed to address the medical necessity of specific services, ensuring that care provided aligns with recognized standards and best practices. Individuals are not excluded from participation in, denied the benefits of, or otherwise subjected to discrimination on the basis of race, color, national origin, sex, age, or disability.

Sources for Policy Development

Policy development involves a comprehensive review of current scientific evidence, utilizing a variety of reputable sources, including but not limited to:

  • Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations (NCD) and Local Coverage Determinations (LCD)
  • Current Procedural Terminology (CPT) 4
  • International Classifications of Diseases 10th Revision (ICD-10)
  • Healthcare Common Procedure Coding System (HCPCS)
  • Correct Coding Initiative (CCI) Edits
  • Blue Cross Blue Shield Association (BCBSA)
  • Web-based literature research

As a member of the Blue Cross Blue Shield Association (BCBSA), Blue Cross & Blue Shield of Rhode Island benefits from access to the BCBSA technology assessment program and Medical Policy Group. These entities facilitate the production of revised and new medical policies, drawing on medical literature, national clinical specialty societies, and expert clinical opinions from national academic medical centers.

All policy development processes take into account, and are crafted to ensure compliance with, the Mental Health Parity and Addiction Equity Act (MHPAEA) Non-Quantitative Treatment Limits, as well as other applicable state, federal, and accreditation requirements.

Management of Medical Necessity Criteria

Certain services may require that specific medical criteria be met, or that particular diagnoses are present, in order to qualify for coverage.

Criteria for determining the medical necessity of services are managed through several resources, including:

  • Internal Medical Policy Group, which includes subject matter experts, MDs, and RNs
  • Vendors such as eviCore, Carelon, and Prime Therapeutics
  • Change Healthcare’s InterQual criteria
  • Community specialty physicians

Policy Communication and Transparency

Drafts of newly developed or updated policies are posted on the BCBSRI website to invite comments from local providers. Reviews and updates of all policies are communicated through the Corporation provider newsletter, Provider Update. All policies are published on the BCBSRI website and are open for comment or questions. Access to these policies does not require a log-in, ensuring that all policies are publicly available.