Medical and behavioral health policies
Information on medical management and evidence-based coverage criteria.
Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) use a combination of medical and behavioral health policies developed by our team of experts and clinical coverage criteria developed by third-party vendors.
To determine the specific criteria and/or source used to determine coverage for a specific type of care, review the prior authorization requirements.
Policies are about coverage, not recommended care
These medical and behavioral health policies in no way imply that members should not receive specific services based on the provider's recommendation. These policies govern coverage and not clinical practices. Providers are responsible for medical advice and treatment of patients. Members with specific healthcare needs should consult an appropriate healthcare professional.
About medical and behavioral health policies
The Blue Cross medical and behavioral health policy team develops evidence-based medical and behavioral health policies. The team presents medical and behavioral health policies to the Blue Cross Medical and Behavioral Health Policy Committee and the Blue Cross Medical Pharmacy & Therapeutics Committee, which are made up of practicing physicians, pharmacists and other providers representing a variety of specialties and Blue Cross representatives.
The Blue Cross Coverage Committee reviews recommendations from the Blue Cross Clinical Committees. Services, procedures, drugs and medical devices are not covered by Blue Cross until final review and approval by the Blue Cross Coverage Committee.
Medical Policy and Pre-Certification / Authorization Router
View an out-of-state Blue Plan's medical policy or general pre-certification / pre-authorization information.
Additional guidelines
Other evidence-based criteria, guidelines and how to access them
- Alternative Health Plans medical policies and guidelines
- eviCore healthcare clinical guidelines
- Federal Employee Program® (FEP®) medical policies and utilization management guidelines
- Prime Therapeutics Management Medical Drug clinical guidelines
- InterQual® criteria: Call provider services at (651) 662-5000 or 1-800-262-0820 to request a copy of a specific InterQual® subset from Change Healthcare.
- MCG Care Guidelines: To view MCG Care Guidelines, providers should log in to Availity.com/Essentials, click “Payer Spaces | Blue Cross Blue Shield of Minnesota” under “Resources.” Members, prospective members, and providers without access to Availity Essentials can email pdl.mcg.support@bluecrossmn.com.
- Substance Use Disorder (SUD) Services, American Society of Addiction Medicine (ASAM)
- Medicare guidelines:
- Minnesota Health Care Programs (MHCP):
Other considerations
Other coverage restrictions may apply
Medical and behavioral health policies apply generally to all Blue Cross health plans. Benefit plans vary in coverage. Some plans may not provide coverage for certain services noted in the medical policies.
Medicare products, Medicaid products and some self-insured plans may have different policies and prior authorization requirements. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law.
Medical technology assessment submissions
New information about medical technologies addressed in the Blue Cross medical and behavioral health policies may be submitted to the Blue Cross medical policy team for review. Email the information to medical.technology.assessment@bluecrossmn.com.
Provider feedback for third-party clinical criteria:
- To submit feedback, complete the Provider feedback form for third-party clinical criteria
- Email the form to: policy.provider.feedback@bluecrossmn.com
Medical policy supporting documents
- See medical policy definitions
- Medical drug evaluation list — new FDA-approved drugs under clinical review
- Preferred Medical Drug Program — Commercial plans
- Medicare Part B Step Therapy Program — Preferred Drug List
Blue Cross reserves the right to revise, update and/or add to these policies at any time without notice. If members or providers have questions about a policy, they should contact Blue Cross.
Support resources
Questions about a medical policy or an appeal?
Providers: Call provider service at (651) 662-5000 or 1-800-262-0820.
Members: Call the number on the back of your member ID card or (651) 662-8000 or 1-800-382-2000 (TTY 711) or log in to your member account and send a secure message to customer service.
Acknowledgements:
The five-digit numeric codes that appear on the documents on this site were obtained from the Physician's Current Procedural Terminology, as contained in CPT® 2022, ©2021 American Medical Association.
Current Dental Terminology, as contained in CDT 2022: Dental Procedure Codes, ©2021 American Dental Association. All rights reserved.
Prime Therapeutics LLC is an independent company providing pharmacy benefit management services.