Policy Bulletin User Information

Policy Types and Descriptions


Policy Types and Descriptions: learn about medical policies, the technology evaluation process, and claim payment policies


Medical Policy

Medical policy bulletins are the Company’s communications to providers, members, and Company associates describing the Company’s coverage position on medical and behavioral health care services. This includes laboratory tests, diagnostic procedures, preventive interventions, and treatments (eg, drugs/biologics, devices, and medical/surgical procedures).

The Company develops new medical policies and revises existing medical policies using various scientifically based, peer-reviewed sources. Medical policies may be developed or revised as a result of any of the following:

  • Emerging and/or new health care technologies
  • Changes in existing technologies
  • Creation of or changes to federal or local contractor Medicare policies
  • Legislatively mandated coverage requirements
  • Scheduled review of existing policies
  • Updates to coding (eg, Current Procedural Terminology [CPT], Healthcare Common Procedure Coding System [HCPCS])

Medical policies are developed and subsequently revised taking into consideration:
  • Technology assessments (Note: Please refer to information below about technology assessments and how they are used in medical policy development)
  • Federal and/or local contractor Medicare policies
  • Other nationally recognized and accepted sources, including the US Food and Drug Administration (FDA)
  • Nationally recognized professional organizations’ opinions, consensus statements, or clinical practice guidelines
  • Manufacturer’s guidelines for use
  • Information about clinical trials used in the FDA regulatory approval process
  • Expert consultant opinion

The process of medical policy development and subsequent policy revision is an established method for consistent development and maintenance of medical policies and procedures in accordance with current standards of care, federal and state mandates, and accreditation standards. These include, but are not limited to those of the National Committee for Quality Assurance (NCQA), a private, not-for-profit agency that maintains accreditation standards for health plans and the Centers for Medicare and Medicaid Services (CMS). Medical Policies are reviewed and updated on an annual basis, or more frequently as new evidence becomes available, and are reviewed and approved by the appropriate committee(s) prior to publication.


Technology Assessment

A technology assessment is a process of identification, review, and evaluation of data about medical products and services (laboratory tests, diagnostic procedures, preventive interventions, and treatments) to assess their safety, effect on health outcomes, and appropriate use. The process is conducted based on adherence to the standards of NCQA. The goal is to use principles of research methodology and evaluation to promote a consistent approach in the evaluation of new technology.

Specifically, a technology assessment provides information on new technology or changes to existing technology. It is based on a review of multimedia sources including any of the following:
  • Published medical literature in peer-reviewed journals
  • Nationally recognized professional organizations’ opinions, consensus statements, or clinical practice guidelines
  • Clinical trial data
  • Manufacturer’s guidelines for use
  • Government agencies
  • Technology review associations and various medical and professional associations
  • Public print mass media

The technology assessment weighs the available evidence against the following criteria:
  1. The technology must have final approval from the appropriate government regulatory bodies.
    • This criterion applies to drugs, biological products, devices, and diagnostics.
    • A drug or biological product must have final approval from the FDA.
    • A device must have final approval from the FDA for those specific indications and the methods of use that are being evaluated.
      • Any approval that is granted as an interim step in the FDA regulatory process is not sufficient.
    • FDA regulation does not apply to procedures that involve implantation of devices.
  2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.
    • The evidence should consist of well-designed and well-conducted investigations published in peer-reviewed journals. The quality of the body of studies and the consistency of the results are considered in evaluating the evidence.
    • The evidence should demonstrate that the technology could measure or alter the physiologic changes related to a disease, injury, illness, or condition. In addition, there should be evidence, or a convincing argument, based on established medical facts that such measurements or alteration affects health outcomes.
    • Opinions and evaluations by national medical associations, consensus panels, or other technology evaluation bodies are evaluated according to the scientific quality of the supporting evidence and rationale. This is frequently necessary for newer technologies where the volume and quality of available studies for review are sparse. In these situations, recommendations from subject matter experts and/or national physician specialty societies can help guide determination of quality. Expert opinion alone is generally not adequate for a positive coverage position, but it may add credibility to available published evidence that may have various biases and flaws.
  3. The technology must improve the net health outcome.
    • The technology’s beneficial effects on health outcomes should offset any harmful effects on health outcomes. “Health outcomes” refers to the measurable physiologic responses of medical nature that are directly attributable to the service on the prevention, diagnosis, detection, symptomatology, prognosis, morbidity, recovery, or mortality related to the medical condition. “Net health outcome” means that the advantages outweigh the disadvantages of the service. Again, the quality of the available evidence plays a pivotal role in the determination of coverage position.
  4. The technology must be as beneficial as any established alternatives.
    • The technology should improve the net health outcome as much as, or more than, established alternatives. Published reports of direct comparisons of the service with established standard treatments for the medical condition provide the best evidence for review. Again, the quality of these types of comparison studies is of paramount importance when using this measure to determine coverage.
  5. The improvement must be attainable outside the investigative settings.
    • To meet this objective, the service must be available to members in our plans and be an acceptable medical practice as evaluated by participating professional providers with direct experience in the practice of that service.

Members of the network provider community (who are board-certified, clinically practicing, specialty-matched consultants) review, evaluate, and critique the resulting technology assessment. National experts may also be enlisted to participate in this review process. This analysis of the research data results in a medical necessity determination.


Claim Payment Policy

Claim payment policy bulletins are the Company’s administrative communications to providers, members, and Company associates describing the Company’s coverage and reimbursement position on a specific topic; the requirements for coverage and reimbursement; the instructions for reporting specific services, a class of services, and/or codes (eg, diagnosis, procedure, procedure code modifier); and/or a description of the claims system logic applied to procedure code combinations.

A claim payment policy is developed or revised as a result of any of the following:
  • Basic product benefits, limitations, or exclusion information
  • Changes to provider, ancillary, or facility contracts
  • Updates to coding (eg, Current Procedural Terminology [CPT], Healthcare Common Procedure Coding System [HCPCS]) and/or claims system conventions
  • Legislatively mandated coverage requirements
  • Scheduled review of existing policies

Although claim payment policies may include statements of coverage and/or reimbursement eligibility when policy requirements are met, individual member benefits must be verified, as they may vary by region, product, and/or contract.

Claim payment policies may be developed without the need for scientific evidence to support their position and use, as these are used primarily to define the processes and procedures for doing business with the Company. These policies are reviewed and approved by the appropriate Company committee(s) prior to publication.





2017 AmeriHealth.