Q1: What is a medical policy?
A1: Medical policy is how BlueCross BlueShield of Tennessee keeps up with new medical technologies and new applications of existing medical technologies, (example: new and existing heart procedures, new and existing treatments for diabetes, etc.).
back to top

Q2: Why does BlueCross BlueShield of Tennessee write or develop medical policies?
A2: So that proven medical treatments are paid for according to the member's contract and so physicians can review the reason for the BlueCross BlueShield of Tennessee decision. The medical policy also allows for appropriate claims payment. The policies are not intended to specify coverage, dollar amounts, or benefit information.
back to top

Q3: How is the need for medical policies determined?
A3: We constantly review various sources for information on new and evolving technologies, (example: professional published peer- reviewed sources).
back to top

Q4: What criteria do we use to determine our medical policies?
A4: BCBST utilizes five technology evaluation criteria to assess whether a technology improves health outcomes such as length of life, quality of life, and functional ability. This criteria allows for consistent scientific evaluation. The technology must meet all of the criteria.

• The technology must have final approval from the appropriate government regulatory bodies (such as the Food and Drug Administration).

• The scientific evidence must permit conclusions about health outcomes.

• The technology must improve the net health outcomes.

• The technology must be as beneficial as any established alternatives.

• The improvement must be attainable outside the investigational setting.

Q5: What do the terms mean that are used to classify a medical policy (medically necessary, investigational, cosmetic)?
A5: The terms medically necessary, investigational, and cosmetic are defined in the glossary section of the medical policy manual
back to top

Q6: How does BlueCross BlueShield of Tennessee use medical policies?
A6: To assist in adjudicating claims and evaluating request for services
back to top

Q7: What happens if my doctor disagrees with a BlueCross BlueShield of Tennessee medical policy?
A7: The doctor can request a medical policy appeal.

The doctor can send published, peer reviewed, evidence-based research studies to the Provider Appeals Department and request a review of the medical information.

Q8: Does my doctor have access to the BlueCross BlueShield of Tennessee Medical Policies?
A8: Yes. From the bcbst.com  home page: select Providers. Under Quick Links, select manuals, then select "Medical Policy Manual." The Web address (URL) is http://www.bcbst.com/providers/mpm.shtml.
back to top

Q9: Do I have access to the BlueCross Blue Shield of Tennessee Medical Policy Manual?
A9: Yes. From the bcbst.com home page: select Providers. Under General Information and Education/Reference Materials select "Medical Policy Manual." The Web address (URL) is http://www.bcbst.com/providers/mpm.shtml. The medical policy manual is written using medical terminology. You may find it necessary to consult your doctor if you have questions or need clarification
back to top

Q10: What do I do if I do not understand the medical terms in the Medical Policy Manual?
A10: Several good medical dictionaries are available for your use on the Internet.
back to top