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 documents are available to you as a reference when interpreting claim decisions.
Search For Medical Policies and Clinical UM Guidelines
To see a list of all medical policies and clinical UM guidelines, visit our Full List page.
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 utilization management 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.
Commercial or FEP plans or lines of business which determine there is not a need to adopt a clinical utilization management 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 utilization management guidelines have been adopted by your plan, or to determine if there are other applicable criteria, please reference the listing provided below.
Clinical UM Guidelines adopted by Empire BlueCross BlueShield
In addition to the documents Empire BlueCross BlueShield maintains for coverage decisions, we may adopt criteria developed and maintained by other organizations. Note that where we have developed a medical policy that addresses a service also described in one of these other sets of criteria, Empire BlueCross BlueShield’s medical policy supersedes.
Empire Blue Cross Blue Shield licenses and utilizes MCG Care Guidelines 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 licensed include:
- Inpatient & Surgical Care
- General Recovery Care
- Recovery Facility Care
- Chronic 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
This document provides a summary of customizations to the MCG Care Guidelines 25th edition (Publish date August 19, 2021).
Customizations to MCG Care Guidelines 25th Ediition
This document provides a summary of customizations to the MCG Care Guidelines 26th edition (Publish date December 9, 2022).
Customizations to MCG Care Guidelines 26th Edition
This document provides a summary of customizations to the MCG Care Guidelines 27th edition (Publish date March 1, 2023).
Customizations to MCG Care Guidelines 27th Edition
Our health plans may use guidelines developed by Carelon Medical Benefits Management, Inc. to perform utilization management services for some procedures and certain members.
Carelon Medical Benefits Management guidelines applicable to Empire Blue Cross Blue Shield programs are maintained by Carelon Medical Benefits Management. Updates to these guidelines can be found on their website.
CarelonRx is an independent company providing pharmacy benefit management services. The pharmacy clinical criteria for injectable, infused or implanted prescription drugs and therapies covered under the medical benefit are available for commercial plans and certain Medicare/Medicaid markets.
There are several different dates that may be associated with a medical policy or clinical utilization management guideline
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.