CurrentPremera BluecrossPolicy N/A

Medical policy and clinical guideline definitions and procedures

Defines terminology and the process the Plan uses to develop, approve, publish, and review medical policies and clinical guidelines; intended for providers and Plan staff involved in coverage decisions.

Policy Summary

PayerPremera Bluecross

PolicyMedical policy and clinical guideline definitions and procedures

Policy CodePolicy N/A

Change TypeAdministrativeno material clinical changes

Effective DateApr 1, 2026

Next Review DateApr 1, 2026

Key ActionFollow applicable policy criteria and member contract language when requesting coverage or prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

annualReview frequency

≥9Committee meetings/yr

Apr 1, 2026Effective

not applicableMedicare Advantage

Coverage Criteria and Administrative Rules

Administrative and development criteria

Guideline statements that support how medical policies are developed and applied

Governance and use: Medical policies are Plan documents developed, reviewed, and revised by registered nurses, physicians, dentists, and/or pharmacists with support from Plan Medical Directors; the Plan Medical Policy Committee (licensed health care professionals) approves policies and reviews new and revised policies (during meetings or by electronic vote).

describes roles and approval process

Sources for policy development: Sources include but are not limited to the BCBSA Evidence Positioning System, Hayes Inc. Knowledge Center, NCCN, UpToDate, national specialty society recommendations, peer-reviewed scientific literature, input from practicing physicians, independent review organizations, and applicable legal, state, or federal mandates.

list of evidence and input sources

Review frequency: Medical policies are reviewed at least once per year; the Medical Policy Committee meets as needed and at least nine times per year.

Policy Summary

PayerPremera Bluecross

PolicyMedical policy and clinical guideline definitions and procedures

Policy CodePolicy N/A

Change TypeAdministrativeno material clinical changes

Effective DateApr 1, 2026

Next Review DateApr 1, 2026

Key ActionFollow applicable policy criteria and member contract language when requesting coverage or prior authorization.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions and Operational Notes

Note

Use medical policies and contract language for coverage decisions

The Plan's clinical review staff use medical policies, clinical guidelines, and member contract language to make clinical coverage decisions. Coverage determinations are made in the context of the member's specific benefit plan; medical policy guidance is secondary to contract provisions, restrictions, and exclusions.

Medical policies, clinical guidelines, and member contract language guide coverage decisions
Member contract provisions supersede medical policies when there is a conflict

Step Therapy

Step therapy

No step therapy requirements are specified in this document.

Documentation Required

Benefit verification/documentation

Providers and members must consult the member benefit booklet or contact Premera customer service to determine coverage, benefit limitations, exclusions, and any plan-specific requirements before providing services. Benefit verification should be completed in advance to confirm eligibility, covered services, prior authorization requirements, and applicable cost-sharing. Documentation that supports medical necessity and that aligns with member contract terms should be submitted with any prior authorization request or claim to avoid denials.

Consult the member benefit booklet or contact customer service to determine benefit limitations and coverage
Complete benefit verification prior to service to confirm eligibility and prior authorization needs
Provide documentation supporting medical necessity consistent with member contract language when requesting prior authorization or filing claims

Denial Risk

Denial risk from failing to meet policy/contract criteria

Coverage determinations are based on medical policies, clinical guidelines, and member contract language. Services that do not meet the applicable contract or medical policy criteria may be denied. Providers should ensure documentation and coding clearly demonstrate that services meet medical necessity and contract criteria to reduce denial risk.

Coverage decisions may be denied if services do not meet policy or contract criteria
Ensure documentation and coding demonstrate medical necessity and conformity with member contract terms

Background

This document is an administrative guideline that explains key terms and describes the Plan's approach to developing, approving, publishing, and reviewing medical policies and clinical guidelines. It is intended for providers and Plan staff involved in coverage decisions and is not itself coverage criteria.

Medical policies and clinical guidelines are developed using evidence sources such as peer-reviewed literature, national guidelines, specialty society recommendations, and input from practicing clinicians and independent reviewers; draft and revised policies are reviewed by clinical staff and Medical Directors and approved by the Medical Policy Committee.

Policies are reviewed on a regular schedule with a minimum frequency of annual review, and the Medical Policy Committee meets at least nine times per year to consider new and revised policies.

Members and providers should consult the member benefit booklet or contact customer service to determine benefit limitations for specific services; the policy also notes that member contracts differ in their benefits and that the Company may update policies as appropriate.

Definitions

inv-09: Experimental or investigational — definition and criteria

DefinitionServices lacking FDA approval, subject to Institutional Review Board oversight, without reliable evidence of effectiveness, or under ongoing clinical trials; additional research required before being considered equivalent or superior to conventional therapies.

Evidence standardReliable evidence includes reports and articles in authoritative peer-reviewed medical and scientific literature and assessments and coverage recommendations published by the Blue Cross and Blue Shield Center for Clinical Effectiveness.

Common examplesA drug or device not lawfully marketable because it lacks FDA approval; services that are the subject of ongoing clinical trials to determine safety or efficacy.

Actionable implicationServices meeting any investigational criteria are considered experimental/investigational and are not established as effective for clinical diagnosis, evaluation, management, or treatment.

inv-10: Medical necessity / medically necessary — definition

DefinitionCovered services and supplies that a physician, exercising prudent clinical judgment, would provide to prevent, evaluate, diagnose, or treat an illness, injury, disease, or its symptoms.

Required attributesIn accordance with generally accepted standards of medical practice; clinically appropriate in type, frequency, extent, site and duration; not primarily for convenience; and not more costly than an alternative service at least as likely to produce equivalent results.

Evidence basisStandards based on reliable scientific evidence published in peer-reviewed literature, specialty society recommendations, and the views of practicing physicians.

Actionable implicationServices that do not meet these criteria may be deemed not medically necessary and may be excluded from coverage.

inv-11: Medical policy — definition of medical policy and evidentiary basis

DefinitionA medical policy is a Plan document generally based on the highest level of available evidence that addresses new or evolving technologies, drugs, services, or supplies and establishes medical necessity or investigational status.

Evidentiary basisPolicies are adopted after careful review of published peer-reviewed scientific literature, national guidelines, local standards of practice, and clinical effectiveness data.

PurposeServe as systematically developed guidelines and a resource for Company staff when determining coverage for specific medical procedures, drugs, or devices.

Actionable implicationThe Company reserves the right to review and update policies as medical evidence and technology evolve; member contracts may impose differing definitions—consult the member booklet for group-specific coverage definitions.

inv-12: Routine test management policy — definition and scope

DefinitionA routine test management policy is based on careful review of published peer-reviewed scientific literature, national guidelines, and local standards of practice.

ScopeUsed to evaluate the clinical appropriateness and reimbursement methodology for laboratory tests.

Evidence sourcesPeer-reviewed literature, national guidelines, and local practice standards inform policy conclusions and reimbursement decisions.

Actionable implicationLaboratory test coverage and reimbursement are determined by this policy when tests meet clinical appropriateness criteria and established reimbursement methodology.

OpenPayer

Medical policy and clinical guideline definitions and procedures

Coverage Criteria and Administrative Rules

Coding

Provider Actions and Operational Notes

Background

Definitions