Application of Medical Necessity Criteria

Clinical staff applies objective and evidence-based criteria for medical services that require medical necessity review. All clinical staff must retain a current unrestricted license. Clinical managers provide oversight of the clinical staff who review services that require the application of medical necessity criteria. The member’s individual circumstances and the local delivery system are considered when determining appropriateness of services. Written policies and procedures provide the staff with direction for appropriately applying the criteria. Clinicians base utilization decisions about care and service solely on the appropriateness related to each member’s specific condition. Clinical review staff has no compensatory arrangements that encourage denial of coverage. Plan medical directors and/or Pharmacists render all denial determinations based on medical necessity. 

Monitoring Utilization

Blue Cross and Blue Shield of Nebraska (BCBSNE) uses various mechanisms to monitor and identify potential underutilization and overutilization of services. This helps ensure that Medicare Advantage members receive the medical services required for health promotion, including acute and post-acute care management. Some examples of these mechanisms include: 

• Results of member satisfaction surveys
• Rate of inpatient admissions 
• Rate of emergency services
• Review of alternative levels of care such as observation 

Process for Approvals and Decisions 

BCBSNE continues to demonstrate its commitment to a fair and thorough utilization decision process by working collaboratively with its participating physicians. A plan medical director reviews all medical necessity determinations that cannot be approved through the application of decision criteria by BCBSNE Care Management nurses. It may be necessary for the plan medical director to contact physicians for additional information about their patients to assist in making a determination. 

Clinical Review Requirements
BCBSNE clinical review process is established to: 

• Ensure uniformity in the provision of medical care
• Ensure the medical appropriateness and cost effectiveness of certain services 
• Improve the overall quality of care BCBSNE members receive 
• Lower the cost of coverage for BCBSNE members