Medical Policy Terms of Use, Disclaimer, and Copyright Information
Defines the purpose, applicability, limitations, and copyright/usage notices for Blue Cross Blue Shield of Massachusetts medical policies; applies to providers, members, and BCBSMA staff who use or rely on BCBSMA medical policies.
No material clinical or coverage changes in this revision.
Coverage Criteria and Applicability
Some benefit plans administered by BCBSMA, including certain self-funded employer plans and governmental plans, may not utilize BCBSMA medical policy. While BCBSMA medical policies generally apply to most fully‑insured plans, local variations in plan design and administration mean that policies may not govern coverage for every plan or service.
BCBSMA medical policies describe when services are medically necessary, investigational, or not medically necessary. This terms‑of‑use document states that policies include determinations about services that are not medically necessary but does not list specific not‑medically‑necessary conditions or scenarios within this general terms‑of‑use statement.
Referenced Coding Systems
| CPT | References CPT codes; Current Procedural Terminology (CPT) is copyright 2022 American Medical Association |
Provider Actions, Authorization & Member Contact
Policy vs. Authorization
Medical policy is not plan authorization. BCBSMA medical policies describe when services are medically necessary, investigational, or not medically necessary, but they do not authorize care or guarantee coverage. Coverage determinations are made based on the member's benefit plan in effect at the time of service.
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