Utilization Management Medical Review Requirements

The BlueCare Tennessee Utilization Management (UM) Program is intended to assure the provision of appropriate health care to all BlueCare and TennCareSelect Members in the most cost-effective manner.

Medical Review Requirements

BlueCareSM and TennCareSelect reviews are based upon Milliman Care Guidelines®, BlueCross BlueShield of Tennessee/Volunteer State Health Plan ("BCBST/BlueCare Tennessee") adopted guidelines, BCBST/BlueCare Tennessee Medical Policy, Bureau of TennCare Rules, and Bureau of TennCare Medical Necessity Guidelines and criteria. Milliman Care Guidelines have developed a series of Best Practices Guidelines regarding common Member care practices. These guidelines are reviewed and approved by a panel of BlueCare and TennCareSelect practicing network Physicians in addition to the national panels used by Milliman Care Guidelines®.

There are times when BlueCare Tennessee must modify or redefine certain Milliman Care Guidelines® criteria to meet practice patterns in Tennessee (i.e., a guideline does not exist, the length of stay needs to be defined, or the decision criteria needs to be modified.) Modified Utilization Management Guidelines are published on the Web site, bluecare.bcbst.com, allowing Providers the opportunity to review and/or be aware of any changes or variances made to Milliman Care Guidelines® by BCBST/BlueCare Tennessee. Providers are notified thirty (30) days in advance of subsequent changes to these guidelines. When the nurse reviewer cannot approve a request, it is referred to a Physician for review.

If the BlueCare or TennCareSelect Physician reviewer denies the review, the Provider may appeal the decision (see Section XII Highlights of Provider Agreement in Provider Administration Manual (PAM) for the appeal process). Please remember that the insurance benefit available for the Member is the focus of the discussion.

Recommendations for submission of records

Submit records hardcopy with cover letter stating what is being requested.

Submit any request letters from us as the first page of your medical record.

If submitting multiple records for a single patient or multiple records for multiple patients, ensure the individual records are secured with a clip or other indicator if mailed in the same envelope.

Pertinent medical records may be submitted through certified mail. These may be mailed to:

BlueCare Tennessee
UM Appeals Department
Attention: BlueCare/TennCareSelect Provider Appeals Supervisor
1 Cameron Hill Circle, Ste 0020
Chattanooga, TN 37402

 

Please note that FedEx will not deliver to a P.O. Box; if using FedEx services, send records to:

BlueCare Tennessee
UM Appeals Department
Attention: BlueCare/TennCareSelect Provider Appeals Supervisor
1 Cameron Hill Circle
Chattanooga, TN 37402-0020
Fax to: 1-888-357-1916

 

Medical records must be legible with all appropriate information pertinent to the presenting case.

Include all member information in a clear, legible format. We must be able to identify the patient and the relationship to BlueCare Tennessee.

Claims must be attached behind the medical record. If attached to the front, it will be mistaken for a claim needing adjudication rather than a medical record needing review.

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