Provider and Facility Reference Manual
PLEASE NOTE: Our website URL will be changing. On February 1, 2023 we will be redirecting this website to our Highmark Provider Resource Center (PRC) website. Click here, to visit the PRC.
Information in this manual applies only to your Highmark BCBSWNY legacy patients who have NOT moved onto Highmark’s system.
For your patients who have moved onto Highmark’s system, please visit the Highmark Provider Manual.
For more information about our affiliation with Highmark, please visit bcbswny.com/workingtogether.
Section 8 - Corporate Medical Protocols
Blue Cross Blue Shield publishes Corporate Medical Protocols to give participating providers a concise overview of medical necessity criteria utilized to determine coverage of services rendered. The Corporate Medical Protocols also identify and explain services that are investigational or experimental. Blue Cross Blue Shield reviews and re-evaluates the Corporate Medical Protocols at least annually and more frequently as new information emerges that affects them. A cover letter describing the changes to the Corporate Medical Protocols is published 30 days in advance of their effective date. The effective date is included in our quarterly provider newsletter, Network News and Updates.
Development of the content included in the Corporate Medical Protocols is discussed in Section 5 under Medical Policy Unit. Updated protocols and cover letters are available to providers.
The Corporate Medical Protocols provide clinically significant information about medical treatment that, if not adhered to, may affect the payment a provider receives. When a service is denied because it does not meet the medical necessity criteria contained within the protocol or the preauthorization requirement is not adhered to, the member is held harmless and cannot be billed. Payment for covered services is always subject to individual contract limitation and member eligibility at the time the services are rendered.
Our written process for evaluating and implementing the Corporate Medical Protocols meets NCQA standard UM 10: Evaluation of New Technology.
Medical Policy Change Request Process
Blue Cross Blue Shield provides an established process for participating providers who disagree with our current position regarding a specific medical treatment or technology. The medical policy review process is designed to eliminate undue influence resulting in an unbiased determination. Reconsideration of our corporate position will be made if/when published, peer-reviewed scientific literature supporting its efficacy becomes available.
A guide to making medical policy change requests can be found on our provider website.