Name of Manual - Blue Cross and Blue Shield of Minnesota

Integrated Health
Management Decision
Making
Integrated Health Management
Integrated Health Management including utilization management
(UM) decision-making is based only on appropriateness of care,
service and existence of coverage. Blue Cross does not compensate
practitioners or other individuals conducting utilization review
decision-making activities for denials of coverage or service. Blue
Cross does not offer incentives to decision-makers to encourage
denials of coverage or service that would result in less than
appropriate care or underutilization of appropriate care and
services.
Blue Cross UM decision-making processes ensure that members
are not discriminated against in the delivery of health care services
consistent with the benefits covered in their health coverage plan
based on race, ethnicity, national origin, religion, sex, age, mental
or physical disability, sexual orientation, genetic information or
source of payment through the use of specific clinical criteria and
consideration of the individual needs of each case.
This statement exists to inform and remind providers, their
employees, their supervisors, upper management, medical
directors, UM directors or managers, licensed UM staff, and other
personnel and UM staff employed by participating providers, who
make utilization management decisions of this philosophy and
practice. This includes delegates conducting utilization
management services on behalf of Blue Cross.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-5