Coverage Policy

Medical Coverage Policy Terms and Conditions

Arkansas Blue Cross and Blue Shield has established specific Coverage Policies addressing certain medical procedures or technologies to assist us in administering health plan benefits.

The purpose of a Coverage Policy is to inform members and their physicians why certain medical procedures may or may not be covered under Arkansas Blue Cross and Blue Shield health plans. In addition to these specific Coverage Policies, all Arkansas Blue Cross and Blue Shield health plans or contracts also include more generally applicable coverage standards known as the Primary Coverage Criteria. The Primary Coverage Criteria apply to ALL benefits members may claim under their plan, no matter what types of healthcare services, supplies or pharmaceuticals (“Health Services”) may be involved or when or where members obtain the Health Services.

Benefit coverage for Health Services is determined by the member specific benefit plan document, such as a Certificate of Coverage, Schedule of Benefits, or Summary Plan Description, and applicable laws that may require coverage for or otherwise apply to a specific service. The member’s specific benefit plan document identifies which Health Services are covered, which are excluded, and which are subject to limitations. In the event of a conflict between the benefit plan document and our policies and guidelines, the member’s specific benefit plan document supersedes these policies and guidelines.

Medical Coverage Policies are developed as needed, are subject to changes and updates, and are reviewed and updated at least annually. Medical Coverage policy is developed through a review of the current published evidence from peer-reviewed, published literature in recognized medical journals from PubMed for a specific health service/drug/device as applicable under the definitions of Primary Coverage Criteria for fully-insured contracts or medical necessity, not medically necessary or investigational/experimental for some self-insured contracts as set forth in specific health plan’s benefits. Additional resources utilized are the Agency for Healthcare Research and Quality (AHRQ), the Cochrane Library, FDA Drug Prescribing Information, evidence-based national physician specialty societies and associations specialty society guidelines, National Institute of Health and Care Excellence (NICE), appropriate government regulatory bodies including state and federal laws, input from external clinical experts and other evidentiary sources.  They represent one of the resources used to support decisions about coverage of your Health Services. Additionally, Arkansas Blue Cross and Blue Shield may use tools developed by third parties with subject matter expertise, such as criteria developed by InterQual.® The plan uses InterQual® criteria to review certain Health Services.  InterQual® criteria is evidence-based criteria that offers guidance in covering medical and behavioral health for all levels of care in addition to care planning, complex care management, durable medical equipment, procedures, and specialty pharmacy. InterQual® criteria are derived from the systematic, continuous review and critical appraisal of the most current evidence-based literature and include input from independent panel of clinical experts.. Sources reviewed through InterQual’s process include PubMed, Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Reviews, AHRQ Technology Assessments, the Cochrane Library, Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations, FDA Drug Prescribing Information, and the National Institute of Health and Care Excellence (NICE). InterQual also reviews information available through other medical literature databases, medical content providers, data sources, regulatory body websites, and specialty society resources. InterQual assesses relevant studies for risk of bias following principles described in the Cochrane Handbook. Observational trials are also evaluated for the presence of a dose-response gradient and the likely effect of plausible confounders. The resulting evidence is then assessed for consistency, directness, precision, effect size, and publication bias by Arkansas Blue Cross before being adopted for use with Arkansas Blue Cross health plans.

Other third-party resources may be utilized to assist in the development and management of Medical Coverage policies such as Carelon Medical Benefits Management, Lucet Behavioral Health Services and Solutions and Avalon Routine Test Management Solution.

A Health Service does not meet Primary Coverage Criteria where there is an absence or insufficient evidence supporting clinical effectiveness and safety of a drug, device, or service under review unless otherwise required by state or federal law or does not meet the evidence-based criteria developed by the third-party vendor.

Medical Coverage Policies are the property of Arkansas Blue Cross and Blue Shield.  The InterQual® criteria are proprietary to Change Healthcare.