Blue Shield's utilization management decisions

The goal of the Blue Shield Medical Care Solutions Program is to promote the efficient and appropriate utilization of medical services and to monitor the quality of care given to members. To accomplish this goal, the program requires systematic monitoring and evaluation of the medical necessity and level of care of the services requested and provided. Blue Shield determines medical necessity and the appropriateness of the level of care through the prospective review of care requested and the concurrent and retrospective review of care provided. These reviews are conducted by Blue Shield clinicians, medical directors, pharmacists, peer review committees, physician peer reviewers and other consultants. 

Blue Shield may also delegate utilization management (UM) activities to subcontracted entities. Blue Shield approval of the delegated entity’s UM program is based on a review of its policies and procedures, demonstration of compliance with stated policies and procedures, and the ability to provide services to our members in keeping with various accreditation and regulatory requirements. All delegated activities are monitored and evaluated by the Blue Shield Health Solutions teams and the appropriate oversight committee to assist the delegated entity in improving its processes. Blue Shield retains the authority and responsibility for the final determination in UM medical necessity decisions and ensures appeals related to utilization issues are handled in a timely and efficient manner. 

Medical necessity reviews (for both authorizations and non-authorizations) made by Blue Shield use a hierarchy of criteria for both medical and Mental Health/Substance Use Disorder (MH/SUD).  Coverage for Mental Health and Substance Use Disorder (MH/SUD) services is provided under the same terms and conditions as those applied to medical/surgical services conditions.  

Medically necessary treatment of a mental health or substance use disorder* means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is:

• In accordance with the generally accepted standards of mental health and substance use disorder care; 
• Clinically appropriate in terms of type, frequency, extent, site, and duration; and 
• Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. 

*This definition applies to MH/SUD benefits in fully-insured products.  

The criteria utilizes generally accepted standards of medical practice in the United States; and clinically appropriate, in terms of type, frequency, extent, site, and duration; and considered effective for the patient’s illness, injury, disease, or its symptoms; and not primarily for the convenience of the patient, physician, or other healthcare provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results for the diagnosis or treatment of that patient’s illness, injury, or disease, or its symptoms; and not part of or associated with scholastic education or vocational training of the patient; and hospital inpatient services which are medically necessary include only those services which satisfy the above requirements, require the acute bed-patient (overnight) setting, and which could not have been provided in a physician’s office, the outpatient department of a hospital, or in another facility at a lower level of care without adversely affecting the patient’s condition or the quality of medical care rendered. The following are services that will not be covered at the inpatient level of care:

• For diagnostic studies that can be provided on an outpatient basis;
• For medical observation level of care;
• For personal comfort;
• In a pain management center to treat or cure chronic pain; or
• For inpatient rehabilitation that can be provided on an outpatient basis.

Blue Shield applies evidence-based clinical criteria and Blue Shield medical policy to determine medical necessity. Blue Shield and Blue Shield Life use the UM criteria found in the following resources to determine medical appropriateness and coverage. The resources are not listed in use order for utilization management and medically necessary decisions. The specific hierarchy for each line of business is determined by regulatory government bodies. For example, Medicare requires use of the Medicare Managed Care Manual and NCD/LCD’s first. 

• Center for Medicare & Medicaid Services (CMS) and other state and federal guidelines
  • Note: The Medicare Coverage Issues Manual for Durable Medical Equipment applies across product lines and can be found online at www.cms.gov; all other services apply to Medicare
• Medicare Local (LCD) and National (NCD) coverage determination
• Medicare Managed Care Manual
• Guide to Clinical Preventive Services: Report to U.S. Preventative Services Taskforce
• Blue Shield medication policies 
• Standardized criteria sets (i.e., MCG®, DSM-5)
• Provider organization criteria or guidelines
• Resources may include MCG®, Medicare Benefit Policy manual coverage guidelines
• World Professional Association for Transgender Health (WPATH)
• American Society of Addiction Medicine (ASAM)
• Early Childhood Services Intensity Instrument (ECSII)
• The Child & Adolescent Level of Care Utilization System (CALOCUS-CASII)
• Level of Care Utilization System (LOCUS)
• Blue Cross® and Blue Shield® Service Benefit Plan Brochure (FEP PPO Plan only)
• Federal Administrative Manual (FEP PPO only)
• Federal Employee Program Medical Policy (FEP PPO only)
• AIM Specialty Health radiology guidelines (DSNP only)
• National Comprehensive Cancer Network Guidelines (DSNP only) 
• DHCS Medi-Cal UM Criteria (DSNP only)

Providers must use the most current version of the policies listed above and manage updates to their UM review processes. For fully-insured products, Mental Health and Substance Use Disorder medical necessity review is conducted by Blue Shield’s MHSA and utilizes the American Society of Addiction Medicine (ASAM) criteria, Level of Care Utilization System (LOCUS) guidelines, Child and Adolescent Level of Care Utilization System (CALOCUS) guidelines, and Early Childhood Service Intensity Instrument (ECSII) guidelines. Additional guidelines may be added as they become available from non-profit professional associations in accordance with California law. Medical services for the treatment of gender dysphoria, eating disorder or substance use disorder are reviewed by Blue Shield utilizing the criteria as outlined in the UM Program Description. 

To request Utilization Management criteria or with questions, contact UM staff by phone or fax:

  Phone:(800) 541-6652 (option #6)

  Fax: (844) 807-8996

The information about utilization management for Blue Shield of California Promise Health Plan providers can be found on Utilization management and clinical practice guidelines page.