Name of Manual - Blue Cross and Blue Shield of Minnesota

Messages You May
Receive
Integrated Health Management
The following message appears on the Statement of Provider
Claims Paid to tell you that we did not receive the information
needed to review the claim:
We cannot continue processing of this claim because the
medical information we requested has not been received. We
will reprocess your claim upon receipt of the requested
information.
During utilization review, claims are screened for medical
necessity. Peer review agents or consultants deny claims only after
careful evaluation. Slightly longer processing time is required for
claims that must go through the utilization review process. The
following messages appear on the Statement of Provider Claims
Paid for utilization review denials:
This contract does not cover charges for treatment, services, or
supplies which do not meet our criteria for medical necessity or
are not normally provided for the treatment of this condition as
determined by our medical staff and/or an independent health
care professional reviewer.
These charges are not covered because this contract does not
allow services from a provider performing this type of health
care.
This service and related charges are considered investigative
and are not covered according to this contract. Our Medical
Policy Committee continually reviews medical procedures in
order to determine the investigative status of this and other
services.
These charges are not allowed because there was no
documentation in the medical records to support this level of
care.
Participating providers agree not to bill the member for any
services Blue Cross determines to be not medically necessary or
investigative. Medical necessity denials can be appealed within 30
days from the date you are notified. We request that you submit
written appeals outlining the issues and ATTACH supporting
documentation such as medical records, operative reports, and any
medical information documenting unusual circumstances at the
time of the request.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-29