Name of Manual - Blue Cross and Blue Shield of Minnesota

Integrated Health Management
Provider Contractual
Obligations –
Important Program
Points
The following points pertain to all of the Integrated Health
Management programs. Any medical necessity denial
determination may be discussed with a physician reviewer by
telephone.
Any services denied using Blue Cross’ medical necessity
guidelines cannot be billed to the member/patient unless you
have specifically notified the member/patient prior to the
service being rendered that the service is medically
unnecessary and will not be covered, and the member/patient
has agreed in writing to pay for the service. This applies to
investigative services as well as some non-covered services for
mental health. (Refer to Waiver Section.)
The Integrated Health Management process is a review for
medical necessity only. Payment for services is still subject to
all other terms of the member contract. Therefore, denials may
occur for preexisting conditions, benefit maximums,
coordination of benefits or riders in the member’s contract, that
supersede medical necessity.
We recommend that you utilize provider web self-service,
BLUELINE or contact provider services to verify coverage,
benefits, contract eligibility and limitations for all patients.
Service representatives will also verify which Integrated
Health Management procedures apply to a patient’s contract.
Providers will be held financially liable for services that are
determined to be not medically necessary during a review or an
audit process, even though pre-certification/pre-authorization
and/or admission review has been requested or is not
recommended.
4-4 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)