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Utilization Management: Coverage and Denial Processes

Date:
January 23, 2020

To: All Providers

Coverage Decisions Based on Appropriateness of Care

BlueCross BlueShield bases medical necessity decisions on the appropriateness of care and services. Coverage decisions are based on the benefits and provisions contained in patients’ contracts. We do not reward or offer incentives to practitioners, providers, or staff members for issuing denials or for encouraging inappropriate under-utilization of care.

Discussing an Adverse Determination

Practitioners who would like to discuss a denial decision based on medical necessity with our physician reviewers may do so by calling 1-800-677-3086

You may also discuss the adverse determination with our physician reviewers at the time you are notified by phone of our determination. You may request the criteria used by Utilization Management to render our decisions by calling the number above or sending a written request to:

BlueCross BlueShield of Western New York
Attn: Utilization Management
PO Box 80
Buffalo, NY 14240-0080

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