Name of Manual - Blue Cross and Blue Shield of Minnesota

Integrated Health Management
Scope and Purpose These policies are applicable to all commercial and government
program products; medical, surgical, and behavioral health
services are included.
Benefit plans vary in coverage and some plans may not provide
coverage for certain services discussed in the medical policies.
Medicaid products may have additional policies and prior
authorization requirements, as well as some self and fully insured
plans. Coverage decisions are subject to all terms and conditions of
the applicable benefit plan, including specific exclusions and
limitations, and to applicable state and/or federal law.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-15