Policies & guidelines

Medical policy

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:

  • The approval process
  • Research sources
  • Definition of medical necessity
  • Technology assessment process
  • Definition of investigational services
  • How we select technologies for policy development
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Reimbursement policy

Reimbursement policy

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.

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Dental policies

Dental policy

Dental policies have been developed through consideration of government approval status, dental necessity, generally accepted standards of dental practice and review of dental literature. Policy changes are published in The Connection.

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Guidelines

Clinical Practice Guidelines

Our guidelines are systematically developed statements on medical practices that help physicians and other practitioners make decisions about appropriate health care for specific medical conditions.

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Clinical Position Statements

Our position summaries are based on certain medical treatments, tests or medications; research from scientific literature; government approval status; and evidence-based treatment guidelines supporting clinical best practices and standards of care.

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