Our policies are used as guidelines for coverage determinations in all of our health care plans, unless otherwise indicated. Benefit determinations are based on applicable member contract language. Plan language will be followed if there are any conflicts between these policies and the Plan.
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The purpose of medical policy is to provide guidelines for determining coverage criteria for specific procedures, equipment and services. The Introduction section of this manual includes information about:
- Approval process
- Research sources
- Definition of medical necessity
- Technology assessment process
- Definition of investigational services
Selecting of technologies for policy development
Reimbursement policy documents our payment policy and correct coding for medical and surgical services and supplies. It is used to provide consistent and predictable claims payment through the systematic application of our member contracts, provider agreements and medical policies.
Medication policies are based upon research of scientific literature, government approval status, and evidence-based treatment guidelines supporting clinical best practice/standards of care.
- Clinical Practice Guidelines (CPGs) are systematically developed statements on medical practices that help physicians and other practitioners make decisions about appropriate health care for specific medical conditions.
- Government Programs compliance tips will help ensure you are compliant with the Government Programs' requirements for delegated and downstream entities (DDEs). You are required to maintain documentation sufficient to us or the Centers for Medicare & Medicaid Services (CMS) that these elements are met.