医疗政策由医疗指南组成, 包括诊断成像管理政策, 报销指南和管理指南.
These guidelines detail when certain medical services are considered medically necessary by 蓝十字数控, 以及他们是否被蓝十字NC公司视为调查对象. (For more information concerning medical necessity and investigational criteria, 请看这些具体的政策.) Our medical guidelines are written to cover a given condition for the majority of people. 每个人的独特, clinical circumstances may be considered in light of current scientific literature. 医学指南是基于不断变化的医学科学, 因此，我们定期审查和更新我们的政策.
作为蓝十字NC诊断成像管理计划的一部分, CT / CTA, MRI/MRA和PET扫描, 以及核心脏病学服务, may require prior plan approval when received on a nonemergency outpatient basis, 比如在医生的办公室里, 医院的门诊部或独立的影像中心1. For detailed information regarding which services are subject to the diagnostic imaging management guidelines, 为哪个成员，在什么情况下, 具体政策详见.
The diagnostic imaging management policies promote the most appropriate use of outpatient diagnostic imaging procedures, 研究的适当顺序, 以及最有效地利用会员利益.
北卡罗来纳州的蓝十字和蓝盾 (蓝十字数控) implemented the 医学肿瘤项目 (Program) effective April 1, 2017. The Program is designed to promote optimal support for our members' cancer care needs, 同时降低了管理成本的最复杂之一, 成员可能会遇到昂贵和流行的疾病. 该计划包括肿瘤学家的在线访问, 泌尿科医生, and hematologists to decision support tools for selecting cancer treatment regimens, 哪些与当前的证据和共识指导方针一致. 除了, the Program includes Cancer Treatment Pathways (Pathways) based on medical evidence and best practices developed with leading cancer experts. Pathways offer support in identifying highly effective therapies that can be often more affordable for our members.
Pathway regimens are widely accepted as a key component to manage oncology quality 和成本s. 比指南更具体, Pathway regimens identify treatments selected based on clinical effectiveness, 有利的毒性资料, 和成本. 癌症治疗途径是基于对疗效的详细回顾, toxicity 和成本 informed by a clinical library and include evidence drawn from:
- expert consensus statements and guidelines from professional organizations including the American Society of Clinical Oncology (ASCO), 美国血液学会(ASH), 以及国家综合癌症网络(NCCN), 以及
- government agencies including the Food and Drug Administration (FDA) and the National Cancer Institute (NCI).
该项目将由AIM Specialty Health®(AIM)管理。. AIM帮助提高合格的蓝十字NC成员的癌症护理质量, 以及 manage the associated costs for certain complex tests and treatments, 通过促进病人护理，这是适当的, 安全的和可负担得起的.
You can find a comprehensive list of oncology drugs included in the AIM 医学肿瘤项目 within our Prior Review (之前计划的批准) Code List at the following link:
Information on our individual medical policies for oncology drugs included with the Program can be found by searching the appropriate drug name within the 分类指数 列在我们的医疗指南中.
These guidelines provide claims payment editing logic for CPT, HCPCS and ICD-10-CM coding. Reimbursement guidelines are developed by clinical staff and include yearly coding updates, periodic reviews of specialty areas based on input from specialty societies and physician committees and updated logic based on current coding conventions.
好处 and eligibility are determined before medical guidelines and reimbursement guidelines are applied. 因此, 医疗政策不是授权, 认证, 利益或合同的解释. 好处 are determined by the group contract and the subscriber certificate that is in effect at the time services are rendered.
These guidelines provide general information regarding the definition of Medical Necessary and Investigational/Experimental services as defined by Blue Cross Blue Shield of North Carolina (蓝十字数控). 另外, a policy for participation in clinical trials is available as an administrative guideline.
在某些市场, 北卡罗来纳州的蓝十字和蓝盾, delegates the Utilization Management for PRIOR REVIEW and CERTIFICATION of specific services or benefits to other companies not associated with 蓝十字数控. 以下是这些公司的名单:
1 Prior review/prior approval is not required when services are performed in an emergency room, 医院(与住院有关), 急诊中心或门诊外科中心.