UTILIZATION MANAGEMENT

We want to make sure you get the best care possible, and we can do that through utilization management. It’s a process in which we review proposed medical services to ensure the treatment being requested is effective and clinically appropriate. By using evidence-based clinical criteria, we can assess the delivery of medical services and medications to determine if they’re appropriate, medically necessary, and of high quality. Utilization management may include pre-service review, urgent concurrent review, post-service review, and filing an appeal.

Our utilization management decisions are based solely on the appropriateness of care and the coverage provided by your plan. We don’t reward health care providers or other individuals in any way for denials of coverage. We offer no financial incentives to encourage decisions that result in less care and fewer services.

The clinical criteria we use to make medically necessary decisions is developed with input from practicing health care providers in relevant specialties and is based on clinical evidence. We review these criteria annually.

This information is intended for reference purposes only. If you have any questions about clinical criteria, consult your health care provider.

Criteria for clinical review

For more information about what your plan covers (technologies, procedures, treatments, supplies, equipment, medications, or other services), read our Medical Policies.

If your plan includes the Standard Control with Advanced Control Specialty Formulary (SC-ACSF), visit the SC-ACSF Clinical Criteria page to review general guidelines that help determine which medications, treatments, or supplies we cover.

If you don’t find the information you're looking for on the Medical Policies or SC-ACSF Clinical Criteria pages, you can complete one of the forms below to receive a copy of the criteria determining what’s included in your coverage of care. Instructions for submitting your request are located at the bottom of each form.

Clinical criteria request forms

The clinical criteria request forms are only for criteria requests. Don't use these forms to request coverage or authorization of any services.

Blue Cross Blue Shield of Massachusetts Clinical Criteria Request Form

Complete and submit this form to request clinical criteria for decisions related to medical, pharmacy, or mental health coverage.

Whole Health Living^®´ Clinical Criteria Request Form

Complete and submit this form to request clinical criteria for decisions related to chiropractic care.