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Medical Management

Blue Cross of Northeastern Pennsylvania is now Highmark Blue Cross Blue Shield. Our members’ coverage will continue to be offered by Blue Cross of Northeastern Pennsylvania until they renew for 2016. Our goal is to work with you to provide our members appropriate care at the right time and in the right setting.

Utilization/Medical Management performs the following processes:

  • Prior Approval (also called precertification/prior authorization): A review of medical information before providing health care services to determine if the care and setting are medically appropriate, according to established criteria or guidelines.
  • Concurrent Review: A review of services during ongoing patient care to determine if the services, member symptoms and treatment plans continue to meet guidelines for the current level of care.
  • Retrospective Medical Claims Review: A review performed after services are rendered, before claims adjudication.
  • Retrospective Precertification Review: A review conducted when services have been rendered to the member without a required prior approval (precertification), due to the provider’s failure to submit a request.
  • Retrospective DRG Audit: A review of medical information that occurs after services are given to ensure clinical appropriateness of facility services and accurate coding/reimbursement and application of benefits.
  • Medical Policy Development: The development of medical policies through evidence-based research to determine the scientific merit of new or improved technologies, devices and procedures.
  • Clinical Coding: The process of applying accurate medical codes (i.e., CPT, HCPCS and ICD codes) to services, as related to benefits and medical policies.

Here are important links to information you’ll need when providing medical care to our members:

Medical Policies and Clinical Guidelines
View our online library of the medical policies and clinical guidelines we use when making coverage decisions.

Services Needing Prior Approval
View the services that need prior approval, as well as information on how to submit a request.

Service Codes that are Not Covered
View codes that are considered not medically necessary or experimental/investigative and not covered”.