Medical Policies and Clinical Utilization Management Guidelines

Healthy Blue uses nationally recognized, evidence-based Medical Policies and Clinical Utilization Management (UM) Guidelines.

The full list of Medical Policies and Clinical Utilization Management Guidelines are publicly available on the Healthy Blue Medical Policy and Clinical UM Guideline subsidiary website — Their purpose is to help you provide quality care by reducing inappropriate use of medical resources.

Determinations of medical necessity are made on a case-by-case basis in accordance with the definition of medical necessity. If the request does not meet established criteria guidelines, it will then be referred to the licensed physician with the appropriate clinical expertise for review.

Find the most recent updates to the Clinical UM Guidelines list below:

Medical Policies and UM Guidelines site

• Medical Policies and Clinical Utilization Management Guidelines
• Claim Denial Explanations

Additional Healthy Blue policies can be found below:

• Vitamin D Testing Policy