Medical Policy Information
The medical policies are developed under guidance of the Internal Medical Policy Committee. The Committee is composed of Blue Cross Blue Shield of Wyoming clinical and coding staff with medical policy accountability. This Committee provides a formal internal review for consensus, awareness and implementation throughout the company.
How Is Medical Policy Evaluated?
The Internal Medical Policy Committee reviews “investigational” medical technologies according to the following technology assessment criteria which have been established by the national Blue Cross Blue Shield Association (BCBSA) and endorsed by BCBSWY:
- The technology must have final approval from the appropriate government regulatory bodies.
- The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.
- The technology must improve the net health outcome.
- The technology must be as beneficial as any established alternatives.
- The improvement must be attainable outside the investigational settings.
“Medical necessity” means a medical service, procedure or supply provided for the purpose of preventing, diagnosing or treating an illness, injury, disease or symptom and is a service, procedure or supply that:
- Is medically appropriate for the symptoms, diagnosis or treatment of the condition, illness, disease or injury;
- Provides for the diagnosis, direct care and treatment of the patient’s condition, illness, disease or injury;
- Is in accordance with professional, evidence based medicine and recognized standards of good medical practice and care; and
- Is not primarily for the convenience of the patient, physician or other health care provider.
Sources for Policy Development
Blue Cross Blue Shield Association
- The Office of Clinical Affairs serves as a technical resource on medical policy issues to Plans.
- The Association’s Technology Evaluation Center (TEC) provides scientific analysis and opinions of complex medical technology issues. This information allows Plan medical personnel to make decisions about which treatments best improve a patient’s health outcomes, resulting in efficient use of health care resources
- TEC is guided by the Association’s Medical Advisory Panel (MAP), a panel comprised of nationally recognized experts in technology assessment, clinical research methodology and implementation, and clinical practice.
Specialty Input
- External Review Organization reviews appeals
Centers for Medicare & Medicaid Services
Member Services/Provider Services
Inquiries about our medical policies can be made to BCBSWY Member Services. Members may also wish to discuss their questions and individual medical situations with their physician. Physicians may want to share documentation with BCBSWY about recent medical advances and guidelines that could enhance our medical policies by contacting BCBSWY Provider Relations.
BCBSWY Member Services
PO Box 2266
Cheyenne, WY 82003
800.442.2376
BCBSWY Provider Relations
PO Box 2266
Cheyenne, WY 82003
888.666.5188