Subject:
Description of the Clinical Policy Committee
Description:
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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.
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Not applicable to this policy.
Policy:
I. Function
The Clinical Policy Committee (CPC) functions to do the following:
A. Identify, prioritize and develop medical policies for the commercial products underwritten by Horizon Blue Cross Blue Shield of New Jersey, Horizon Healthcare of New Jersey, Inc. and Horizon Insurance Company, and for the self-insured products, as applicable. Medical policies, as approved by the commercial Horizon Clinical Policy Committee, also apply to products administered by Government Programs if Government Programs has no comparable medical policy.
B. Provide medical expertise and experience in policy development.
C. Assist in researching medical issues, obtaining specialty consultations and feedback from the medical community on policy issues.
D. Review and update existing medical policies as necessary.
Furthermore, the CPC reports to the Quality Improvement (QIC) and it shall review and advise on the clinical content, validity and appropriateness of Medical and Pharmacy policies.
Goals:
A. To develop medical policies that:
1. reflect evidence based best medical practices.
2. promote a high standard of quality care.
3. promote efficient and appropriate use of resources.
4. minimize risk to our membership.
B. To evaluate emerging and new technologies.
C. To identify services that result in improved clinical outcomes.
D. To assist in the education of internal and external customers regarding medical policy.
II. Chairperson
The Chairperson of the CPC shall be the Medical Director of Medical Policy or his/her designee. In his/her absence, an alternate Medical Director may be appointed by the Chief Medical Officer to serve as Chairperson.
III. Committee Composition
The composition of the CPC shall include the following Voting Members:
1. Chairperson (tie breaker voting member only) or his/her designee.
2. At least one (1), but no more than three (3) Participating Providers who shall be licensed physicians and/or other licensed healthcare professionals, and who are currently credentialed to participate in the Horizon Managed Care and/or Horizon PPO Networks, and who are not employees of Horizon BCBSNJ or a related entity.
3. At least two (2), but no more than four (4) Horizon Medical Directors from the Health Care Management Division (“HCM Medical Directors”). Alternate Horizon Medical Directors may be selected by the Chairperson to serve as voting members as needed.
4. At least one (1) Horizon Behavioral Health Medical Director.
5. At least one (1) Horizon Medical Director serving our Major Accounts.
The CPC may include non-voting members who shall serve on the CPC in a consultative (non-voting) capacity only. This may include, but not be limited to, the Director of Quality Management, the Director of Care Management, a Clinical Pharmacist from Pharmacy Management, and representatives from the Medical Policy Team.
IV. Term of Office/Others Attending
Appointments to the CPC shall be made by the Chairperson. CPC members shall serve for one year terms without limitation on the number of consecutive terms served. Reappointment shall be determined annually by the Chairperson. Members not in attendance at four (4) or more pre-scheduled meetings in any twelve month period may be removed and/or replaced at the discretion of the Chairperson.
At the discretion of the Chairperson, other medical and non-medical personnel with applicable subject matter expertise may attend and participate on the CPC in a consultative (non-voting) capacity on an ad hoc basis.
V. Frequency of Meetings/Voting/Quorum
The CPC shall meet no less than ten (10) times per year.
At any meeting of the CPC, a majority of the Committee membership shall constitute a quorum.
For any scheduled committee meeting, the Chairperson shall make a good faith effort to maintain a fair balance of internal vs. external members.
Any action of the CPC shall be taken by a majority vote of the Voting Members present. The Chairperson or his/her designee shall only vote in the event of a tie.
Attendance records shall be maintained.
Voting privileges may not be assigned to alternates attending in place of Committee members.
VI. Issues Log/Agenda/Minutes
An issues log will be generated under the direction of the Chairperson. Copies of the issues log shall be distributed to members of the CPC. All preliminary research on agenda items shall be done prior to the meeting and documentation shall be released with the agenda prior to the meeting. Members shall review all materials prior to the meeting date. The approved committee issues log shall be maintained.
Minutes will be recorded under the direction of the Chairperson. Minutes of the previous meeting should be released to the Committee members five (5) business days prior to the next meeting. Meeting minutes will be retained in accordance with Horizon's record retention policy.
VII. Confidentiality
Member, physician and provider confidentiality shall be maintained.
VIII. Conflict of Interest
If at any point during a meeting, an external voting member identifies a conflict of interest regarding an agenda item, he/she must identify the conflict of interest and abstain from voting on that agenda item. This does not preclude the individual from providing relevant input to the discussion as long as their conflict of interest is revealed before any discussion begins.
All external voting members of the CPC shall be required to complete a Conflict of Interest questionnaire on an annual basis.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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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.
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Index:
Description of the Clinical Policy Committee
Clinical Policy Committee, Description of the
References:
Not applicable to this policy.
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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
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