Blue Shield of California Promise Health Plan and its contracted IPAs and medical groups utilize clinical practice guidelines as standards of health care applicable to members and providers.
The Blue Shield Promise Quality Management Committee performs a review of nationally and locally developed guidelines and gives final approval of the adoption of all guidelines.
All clinical practice guidelines are based on scientific evidence, review of the medical literature, or appropriately established authority, as cited. All recommendations are based on published consensus guidelines that do not favor any specific treatment based solely on cost consideration.
The recommendations for care are suggested as guides for making medical necessity clinical decisions. Clinicians and their patients must work together to develop individual treatment plans tailored to the specific needs and circumstances of each patient.
Providers and members have the right to request a copy of a guideline that Blue Shield Promise has used to make a treatment authorization decision.
The guidelines utilized by Blue Shield Promise come from a variety of sources including:
- Centers for Medicare & Medicaid Services (CMS)
- National Coverage Determinations
- Local Coverage Determinations
- CMS Benefit Interpretation Manuals
- Medi-Cal Coverage Guidelines
- Milliman Care Guidelines®
- National Guideline Clearinghouse
- Evidence in the peer-reviewed published medical literature
These guidelines are developed through:
- Technology assessments and structured evidence reviews
- Evidence-based consensus statements
- Expert opinions of healthcare providers
- Evidence-based guidelines from nationally recognized professional healthcare organizations and public health agencies
Blue Shield of California Promise Health Plan affirms that it encourages appropriate utilization of medically necessary member care and discourages under-utilization of services by the following statements:
- Utilization management (UM) decision making is based only on appropriateness of care and service and existence of coverage.
- Blue Shield of California Promise Health Plan does not specifically reward practitioners or other individuals for issuing denials of coverage or service care.
- Financial incentives for UM decision makers do not encourage decisions that result in under-utilization.
- Providers and practitioners are not prohibited from acting on behalf of the member.
- Physicians cannot be penalized in any manner for requesting or authorizing appropriate medical care.
- Practitioners are ensured independence and impartiality in making referral decisions that will not influence:
- Any other similar matters