Name of Manual - Blue Cross and Blue Shield of Minnesota

Integrated Health
Management Medical
and Behavioral Health
Clinical Staff
Integrated Health Management
IHM medical and behavioral health clinical staff is responsible for
the coordination of utilization management functions for eligible
members. Clinical staff is required to maintain an active
unrestricted health license in Minnesota. The IHM medical and
behavioral health clinical staff is permitted to approve requested
authorizations based on plan documents, policies, procedures, and
established medical and behavioral health clinical criteria.
Physicians or appropriately licensed peer reviewers make
necessary medical necessity denials.
Contractual benefits, medical necessity, appropriateness, and
individual needs are evaluated during the review process to
determine coverage of services. All requests for services that do
not meet medical necessity criteria are reviewed through the
physician peer review process.
UM decision-making is based only on appropriateness of care and
service, and existence of coverage. No financial incentive is
awarded to clinical staff for denying requests for service or based
on coverage decisions.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-7