Blue Care Network Policies and Practices
Our Medical Review staff works closely with your doctor to make sure you get good medical care according to standard medical practice and your health benefits package.
Decisions about a member’s care are based solely on the appropriateness of care prescribed in relation to the member’s specific medical condition. Our clinical reviewers do not have financial arrangements that encourage denial of coverage or service. Nurses and physicians employed by Blue Care Network do not receive bonuses or incentives based on their review decisions. Medical review decisions are based strictly on medical necessity and providing high-quality care for members within the limits of their coverage.
We keep up with changes in health care through an ongoing review of new services, procedures and drug treatments. Our goal is to make coverage decisions in the best interest of our members’ health.
A committee of Blue Care Network physicians, nurses and representatives from different areas in the company is responsible for reviewing new technology requests and making recommendations. In our research we use a variety of resources, which may include:
- Published scientific studies from peer-reviewed medical literature or comparable sources
- Recommendations from the facility or physician proposing to perform the procedure or test
- The U.S. Food and Drug Administration
- The National Institute of Health
- The National Cancer Institute
- Other medical sources as appropriate, including national and local Medicare and state Medicaid coverage guidelines
- The Blue Cross and Blue Shield Association
After reviewing the literature, the committee makes a recommendation to BCN’s senior vice president and chief medical officer about including the service, procedure or drug treatment as a benefit.
Blue Care Network uses third-party administrators to process claims. Our third-party administrators do not ensure that any medical expenses of individuals covered by BCN will be paid. BCN is responsible, at its cost, to respond to and to defend claims seeking the provision of benefits or the payment of medical expenses. All respective duties and responsibilities of the third party administrators and BCN under their agreements are governed by Michigan law.