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Our policies are used as guidelines for coverage determinations
in all health care insurance products, unless otherwise
indicated. Benefit determinations are based on applicable
member contract language. Plan language will be followed
if there are any conflicts between these Policies and
the Plan.
Newly established or revised medical, reimbursement
and administrative policies and information on quality
improvement activities may be communicated in our newsletter, The
Connection OnlineSM, or by letter.
It is important that physicians, other health care
professionals, facilities and their staff review each
issue to keep abreast of these policies.
Provider Incentive Plans
Any provider incentive plans established by Regence BlueShield shall be designed to improve the quality and efficiency of health care provided to its members.
If a provider incentive plan is based on the utilization of health care services, the plan must contain mechanisms to ensure that members are receiving medically necessary health care.
Such mechanisms may include, but are not limited to:
- audits of case files
- overall assessment of causes of utilization pattern variation, and
- offsetting financial incentives that relate to quality
For more information about specific policies, select
the appropriate manual:
| Medical
Policy |
The purpose of medical policy is to provide
guidelines for determining coverage criteria
for specific procedures, equipment and services.
The Introduction section of this manual includes
information about:
- Selecting Technologies
- Research Sources
- Technology Assessment
- Approval process
NOTE: Regence Medical Policy does
not apply to Medicare and Regence MedAdvantage.
Review the Medicare
Advantage Plans (PDF) section
for more information. |
| Behavioral
Health Policy |
These policies are developed using evidence-based
treatment guidelines as well as clinical best practices/standards
of care. They are consistent with Milliman, Substance
Abuse and Mental Health Services Administration
(SAMHSA) and culturally competent practice philosophy
and standards. |
Reimbursement
Policy |
These policies document Regence payment policy
and correct coding for medical and surgical services
and supplies. |
| Other
Manuals |
Description |
Dental
Policy |
Dental policies have been developed
through consideration of government approval
status, dental necessity, generally accepted
standards of dental practice and review of dental
literature. |
Medication
Policy |
Regence medication policies are
based upon research of scientific literature,
government approval status, and evidence-based
treatment guidelines supporting clinical best
practice/standards of care. |
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