Welcome

Welcome to the Medical Policy section of the Mountain State Blue Cross Blue Shield website. This section offers:

• a link to Mountain State's current medical policies;



• a link to Highmark's medical policies, which Mountain State will adopt and begin using in August, 2005;



• a discussion of how medical policies are used;



• an overview of how medical policies are developed, including input from professional providers; and



• a preview of upcoming changes related to medical policy, stemming from Mountain State's impending move to a new claims system.

How Medical Policies Are Used

Medical policy guidelines have their foundation in our subscribers' health benefit contracts with Mountain State. Two important provisions in these agreements are the requirement that services be medically necessary and the exclusion of coverage for experimental/investigational procedures. Medical policies are developed to support coverage determinations under these two provisions.

"Medically necessary" is defined in Mountain State's standard benefit contracts as a service or supply that is required to diagnose or treat an injury, ailment, condition, disease, disorder or illness and which Mountain State determines is:

• appropriate with regard to standards of good medical practice;



• not primarily for the convenience of the subscriber or provider;



• the most appropriate supply or level of service which can be safely and adequately provided to the subscriber in the most cost-effective setting.

"Experimental or Investigational" is defined as a treatment, service, procedure, facility, equipment, drug, service or supply ("intervention") that has been determined not to be medically effective for the condition being treated and therefore is considered experimental/investigational in nature. An intervention is considered to be experimental/investigational if:

• the intervention does not have FDA approval to be marketed for the specific relevant indication(s); or



• available scientific evidence does not permit conclusions concerning the effect of the intervention on health outcomes; or



• the intervention is not proven to be as safe or effective in achieving an outcome equal to or exceeding the outcome of alternative therapies; or



• the intervention does not improve health outcomes; or



• the intervention is not proven to be applicable outside the research setting.

These criteria apply even if there is no available alternative to treat an injury, ailment, condition, disease, disorder or illness. This determination will be made by Mountain State, in its sole discretion, and will be conclusive.

Disclaimer

It should be noted that the definitions of "medically necessary" and "experimental/investigational," as well as coverage, may vary for individual subscribers, based on the specific terms of their particular benefit contracts.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Mountain State's coverage and reimbursement guidelines. Mountain State retains the right to review and update its medical policy guidelines at its sole discretion.

Acknowledgement

The five-digit numeric codes that appear on the Mountain State and Highmark medical policies accessible via this website were obtained from the Physician's Current Procedural Terminology, as contained in CPT-2005, Copyright 2004, by the American Medical Association. This includes CPT descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures and other materials that are copyrighted by the American Medical Association.

Mountain State's Current Medical Policies

Mountain State's medical policies are initially researched and drafted by an internal Medical Policy Committee, chaired by a Medical Director. Draft policies are then presented to Mountain State's two Medical Advisory Committees or "MACs" (one in the northern part of the state and one in the south) for input, revision, and ultimate approval. The voting members of the MACs consist of practicing physicians of various specialties who participate in Mountain State's networks. Individual specialists with expertise in the service under review may also be consulted.

As a relatively small health plan, Mountain State's resources to research and develop its own medical policies -- for the literally hundreds of new and existing treatment services and technologies available -- are limited. Consequently, to augment the relatively few policies Mountain State itself has developed, we rely upon medical guidelines developed by nationally recognized organizations such as Highmark, the Blue Cross Blue Shield Association, and the Centers for Medicare and Medicaid Services.

Planned Adoption of Highmark's Medical Policies And Clinical Edits

Although we remain a West Virginia not-for-profit health services corporation, Mountain State has entered into an affiliation with Highmark, Inc. Highmark does business in western Pennsylvania as Highmark Blue Cross Blue Shield. In the remainder of Pennsylvania, it does business as Highmark Blue Shield. Like Mountain State, Highmark is one of the remaining nonprofit Blue Cross and Blue Shield plans.

One of the major benefits of the Mountain State/Highmark affiliation is Mountain State's ability to access Highmark's state-of-the-art technology and systems. In August, 2005, Mountain State will migrate from its aging claims system to Highmark's BluePRINT system. BluePRINT is a highly sophisticated and integrated group of applications that support claims processing, customer service, membership, billing and medical management.

Highmark's medical policy guidelines have been integrated into its claims processing system, allowing for cost-effective claims processing and ensuring consistent administration of its customers' health benefits. Because the Highmark medical policies are integrated into the BluePRINT system, and because Mountain State will benefit from Highmark's greater resources for researching, developing and updating medical policies, Mountain State will adopt and begin formally using the Highmark medical policies when we migrate to the BluePRINT system.

In addition to clinical guidelines for making medical necessity and experimental/investigational determinations, Highmark's medical policies also contain coding and reimbursement guidelines addressing global services, bundling/unbundling, services considered to be an integral part of a primary service, and other coding and reimbursement-related issues. These guidelines are also integrated into Highmark's claims processing system.

Currently, Mountain State utilizes the McKesson Corporation ClaimCheck® clinical auditing software, as tailored by Mountain State, for some of Mountain State's coding and reimbursement guidelines. Effective with the migration to BluePRINT, Mountain State will cease using ClaimCheck and will adopt and utilize the Highmark guidelines integrated into the BluePRINT system.

One benefit of this change is that these coding and reimbursement guidelines, as reflected in the Highmark medical policies to be adopted by Mountain State, will be readily accessible on the Mountain State website for review by providers who furnish services to Mountain State's subscribers.

It should be emphasized that Mountain State, through its Medical Directors, will continue to make its own independent coverage decisions using the newly-adopted medical policies.

Highmark's Medical Policies

Highmark is a nationally recognized industry leader in developing and implementing up-to-date, medically sound policy guidelines. These policies are developed and maintained according to national accreditation standards such as NCQA and URAC, and the national Blue Cross Blue Shield Association.

Highmark's medical policies address hundreds of issues, such as anesthesia services, consultations, durable medical equipment and supplies, pathology, diagnostic medical services, radiology, nuclear medicine, surgery, cosmetic versus reconstructive surgery, maternity services, therapies, and evaluation and management services.

These policies are based on substantial professional input, including:

• a system of about 280 professional consultants (actively practicing health care professionals) who provide current expert information;



• current medical literature, including the published results of clinical studies;



• FDA or other regulatory approval, where applicable;



• state and national professional organizations (such as the Pennsylvania Medical Society or the American Medical Association) that provide position papers;



• guidelines from national organizations such as the Centers for Medicare and Medicaid Services (CMS), and the Blue Cross Blue Shield Association.

Link To Highmark Medical Policies

Highmark has authorized Mountain State to provide access to its medical policies so that we may furnish our participating providers with as much information as possible about the BluePRINT migration, the policies we will be adopting, and how this may affect you. Please note that these policies will not be applicable to Mountain State business until: (1) the migration to BluePRINT; and (2) the official adoption (with any necessary or appropriate revisions) of these policies as Mountain State policies.

You may search and review the New Mountain State Medical Policies by following the directions summarized below.

As indicated on the link, you may search the new Mountain State medical policies by keyword (e.g., nerve blocks, anesthesia), code (e.g., 99212, 250.9) or policy number (e.g., A-10) if known. A second option is to search by section, meaning category of service (e.g., anesthesia, consultations, maternity, radiology, surgery, visits).

You may also search an alphabetical or sectional index of all policies by clicking on "Index of All Policies" at the bottom of the main search page.

Future Process For Developing And Updating Mountain State Medical Policies

Changes are planned to the procedures for adoption and revision of Mountain State medical policies, in conjunction with the move to the BluePRINT system. The new procedures will be communicated to network providers once they are finalized.

It is anticipated that the new procedures will involve input into the Highmark medical policy process by the Mountain State Medical Directors and clinical staff, and the Mountain State Medical Advisory Committees. We are also in discussions with Highmark about the feasibility of developing a network of professional consultants from Mountain State's participating providers, who would have input in the development of medical policy.

Medicare Advantage PPO Medical Policies

If approved by the Centers for Medicare and Medicaid Services (CMS), Mountain State plans to offer Medicare Advantage PPO products to seniors in our service area beginning this fall. With respect to medical policies, CMS requires that Medicare Advantage plans follow CMS national policy and the regional Medicare Part B carrier's local policy guidelines.

Consequently, Mountain State will not use either its current medical policies (developed for our non-Medicare commercial products) or the Highmark policies (developed for Highmark's non-Medicare commercial products) as the primary medical policies for our Medicare Advantage products. We will use these policies, when appropriate, only as "gap-fill" policies, where there is not a CMS or local carrier policy applicable and appropriate.

Questions, Comments, Suggestions

If you have any questions or comments regarding either the Mountain State or Highmark medical policies, or suggestions for improving this section of our website, please contact the Mountain State Office of Provider Relations at 1-800-798-7768, or ask your External Provider Relations Representative.

Current Mountain State Medical Policies

New Mountain State Medical Policies (effective August 1, 2005)