Name of Manual - Blue Cross and Blue Shield of Minnesota

Integrated Health Management
Focused Utilization Review
Overview Focused utilization review programs contribute to our goals of
containing health care costs by assuring that services are contract
benefits and appropriate. Blue Cross systematically monitors
services of providers for patterns of overuse, underuse, misuse and
abuse in addition for obsolete or questionable practices.
Blue Cross has data warehousing and software programs that look
for patterns outside established norms. The analysts review
medical records and work with providers to resolve questions on
coding, benefits and medical necessity. On-site audits, using a
sample of up to the last three years of claims history may be
performed. Prompt response to medical records requests will speed
up processing of claims under review. Claims are denied as
provider liability if the necessary information is not received
within 14 calendar days.
4-28 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)