Medical Policy Development, Adoption and Reviewing Form
Form and process for practitioners to submit input on development, adoption, and application of Utilization Management (UM) clinical criteria for Blue Cross Blue Shield - North Dakota; affects providers and organizations submitting policy change or new policy requests.
No material clinical or coverage changes in this revision.
Coverage Criteria
This administrative submission form does not establish coverage decisions, medical necessity rules, or explicit coverage exclusions. It is a vehicle for practitioner input on the development, adoption, and application of Utilization Management (UM) clinical criteria and therefore does not specify benefit determinations or claim-level coverage rules.
Provider Actions and Submission Instructions
Submission and Documentation Requirements
No prior authorization is required for submitting this form — the document is a submission form and does not list prior authorization requirements. Submit the completed form and any relevant attachments to the address below; expect follow-up within three to four business days and a final response in about six weeks.
- Submit completed form and attachments to: medicalpolicy@bcbsnd.com
- Include provider/contact information: company/organization name, provider name, contact person, title/role, phone number, email address
- Indicate type of submission: Existing Medical Policy / Request for Policy Change / Request for New Policy / Other (specify)
- If applicable, include Policy Name and Number
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