| |
 | | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
 | Policy Bulletin User Information
 | |
| | |
| | |
| | |
| | |
| | |
| Medical Policy Bulletins | |
|
| |
| | |
| | |
| | |
| | |
| A medical policy bulletin is the Company's communication to providers, members, and Company associates that describes the Company's medical necessity position on medical and behavioral health care technologies. This includes laboratory tests, diagnostic procedures, preventive interventions, and treatments (eg, drugs/biologics, devices, and medical/surgical procedures). Medical policies also provide definitions of diagnoses, guidance on patient selection criteria, applicable places of service, and/or provider types appropriate to the policy topic.
The Company develops new medical policies and revises existing medical policies using various scientifically based, peer-reviewed sources. A medical policy is 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 carrier 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 using:
- Technology assessments
- Federal and/or local Medicare policies
- Other nationally recognized and accepted sources, including the US Food and Drug Administration
- National physician specialty society recommendations
- 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 input
The process of medical policy development, and subsequent policy revision, establishes a 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 that of the National Committee for Quality Assurance (NCQA), a private, not-for-profit agency that maintains accreditation standards for health plans, Centers for Medicare and Medicaid Services (CMS), and URAC, formerly known as the Utilization Review Accreditation Commission. Medical policies are reviewed and updated on an annual basis, or more frequently if needed. The policies are reviewed and approved by the appropriate Company committee(s) prior to publication. | |
|
| |
|