Subject:
Medical Policy Development Policy and Procedures
Description:
_______________________________________________________________________________________
IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
__________________________________________________________________________________________________________________________
Policy:
Purpose of Medical Policy:
The purpose of the Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) Medical Policy Manual is to provide information applicable to the administration of health benefits. The Medical Policies are specifically written to address the clinical circumstances of the majority of people. An individual’s unique clinical circumstances (e.g., age, comorbidities, complications, progress of treatment) will, however, be considered in conjunction with these policies and peer-reviewed, evidence-based scientific literature in the administration of health benefits.
Policy Development and Approval:
New and existing services, treatments, procedures, equipment, devices, supplies, or drugs (collectively "technology") related to physical and behavioral health, pharmaceuticals and devices, are reviewed periodically and as necessary when significant new information is available, to determine medical necessity.
The Clinical Policy Committee is responsible for developing medical policies as well as addressing all medical policy related issues. [Please refer to the Description of the Clinical Policy Committee (Policy #002 in the Introduction Section) for further information about the Clinical Policy Committee.]
Sources for Identification:
Horizon BCBSNJ utilizes the following sources to identify the need to develop and update medical policies::
- UpToDate
- NCCN Guidelines
- Agency for Healthcare Research and Quality (AHRQ)
- Pharmacy Pipeline
- NCCN Compendium
- Medline or PubMed
- FDA (Food and Drug Administration)
- Blue Cross and Blue Shield Association TEC Assessments
- CMS NCDs and LCDs
- Medical Journals
- Position statements, information and recommendations from various medical societies and specialty societies
- Feedback from internal sources (e.g., Medical Directors, Appeal Committees, Pharmacy Committees, Medical Committees including but not limited to, Medical Policy Advisory Committee and the Utilization Management Subcommittee, complaints, reports, various departments, employees, etc.)
- Feedback from external sources (e.g., participating and non-participating physicians/health care professionals, professional societies, independent medical consultants, members, vendors, delegates, regulators, etc.)
- Horizon BCBSNJ Mandate Reference Library (for any pertinent or applicable Federal and/or New Jersey State laws and mandates).
Process:
Upon identification of a potential topic for policy development related to a new technology or new application of an existing technology, the following subcommittees of the Clinical Policy Committee are involved:
A. Pre-Policy Development (PPD)
- informatics report, utilization data, and background information related to the technology are presented and reviewed;
- the need for medical/pharmacy policy development or revision is determined;
- financial/actuarial impact is identified;
- potential administrative impact on policy implementation, pre-authorization and claims policy are also determined;
- preliminary determination related to 'material adverse change' is performed
B. Clinical Policy Working Group (CPWG)
- information and data from research of the professional literature, published scientific evidence, appropriate government regulatory bodies, and other sources of information (e.g., industry policy examples) pertinent to the technology are presented and reviewed;
- input from professionals, specialists and specialty societies may also be compiled and presented;
- medical necessity and policy position related to the technology are determined and reflected on a draft of new or revised medical or pharmacy policy
C. Clinical Policy Committee (CPC)
- draft medical or pharmacy policies are presented for validation and approval.
The following considerations guide the Clinical Policy Committee in developing and in subsequently reviewing every Horizon BCBSNJ medical policy:
A. Whether the technology (treatment, procedure, device, supply, or drug) is safe or provides minimal risk to patients.
B. Whether the effectiveness of the technology is established through:
1. Review of Medical Policy Reference and Technology Evaluation Center Assessments Manuals developed by Blue Cross and Blue Shield Association.
2. Independent search of medical literature and published clinical guidelines; independent research organizations.
3. Consultation with experts in the specific policy area including practicing physicians in New Jersey (e.g., Specialty Liaison Committees, and specialty medical societies and Alliance partners ).
4. Information from appropriate government regulatory bodies.
C. Whether the health outcome is equal to or better than any alternative.
D. Whether any Federal and/or New Jersey State laws or regulations are applicable to the technology.
Internal Review and Feedback
Before draft medical policies are presented to the Clinical Policy Committee for approval, they are electronically circulated to key Horizon BCBSNJ personnel for review and feedback.
External Review and Feedback
Participating physicians and other health care professionals can submit comments and/or recommendations through the website to the Clinical Policy Committee.
Posting, Finalizing and Distributing Approved Medical Policies:
New medical policies as well as existing medical policies with major revisions are posted on the Horizon BCBSNJ corporate website for at least 30 days prior to finalization in compliance with the Health Claims Authorization, Processing and Payment Act ("HCAPPA") requirement. Alternatively, policies determined to constitute a 'material adverse change' (MAC) are posted for at least 90 days. Once this requirement is met, these policies are finalized and are formally added to the Medical Policy Manual. Existing medical policies that have been reviewed and approved by the Clinical Policy Working Group with either minor or no revision are directly added to the Medical Policy Manual. A monthly notification is sent to the clinical as well as key non clinical staff identifying the approved medical policies.
Utilization Management (UM) Vendor Programs:
Horizon reviews, approves and adopts all medical policies/clinical guidelines used by Vendors in managing Horizon UM Programs.
________________________________________________________________________________________
Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
___________________________________________________________________________________________________________________________
Index:
Medical Policy Development Policy and Procedures
Development, Medical Policy
Policy, Development of Medical
Procedures, Medical Policy Development
References:
Not applicable to this policy.
_________________________________________________________________________________________
Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
____________________________________________________________________________________________________________________________ |