Our policies are used as guidelines for coverage determinations in all health care insurance products, 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.
Newly established or revised medical, reimbursement and administrative policies and information on quality improvement activities may be communicated in our newsletter or by letter. It is important that physicians, other health care professionals, facilities and their staff review each issue to keep informed of these policies.
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:
- Selecting of technologies for policy development
- Research sources
- Definition of medical necessity
- Definition of investigational services
- Technology assessment process
- Approval process
Reimbursement policy documents our payment policy and correct coding for medical and surgical services and supplies.
Dental policies have been developed through consideration of government approval status, dental necessity, generally accepted standards of dental practice and review of dental literature.
OmedaRxTM medication policies are based upon research of scientific literature, government approval status, and evidence-based treatment guidelines supporting clinical best practice/standards of care.
Note: Medications that have associated medication policies are also subject to prior authorization requirements.
Clinical Position Statements contain our clinical position on certain medical treatments, tests or medications.
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.