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Policies

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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