Medical Policy Development & Use

The Medical Policy Manual is utilized by the Health Management staff in performing reviews to guide them in determinations of medical necessity and coverage limitations not otherwise specified in the Certificate of Coverage. These reviews are generally conducted prior to the service being rendered.

Policy development
The research and formulation of written medical policies supports medically appropriate and cost-effective health care services. The process includes identification of medical services, technology assessment, or coverage issues requiring a new or revised written medical policy. A comprehensive review of the identified issues is done and the medical policy documentation is developed utilizing the following criteria:

• Research supports the safety, effectiveness and appropriateness of the service.
• Medical community in general accepts the effectiveness of the services outside of the investigational settings.
• Cost/benefit and outcome data are similar to established services.
• Service has been approved by the appropriate regulatory bodies, if necessary.
• Certificate of Coverage or Summary Plan Document language is consistent with policy.
• Legal/risk management issues are considered.
• Financial implications to the plan are reviewed.

Use of medical policies
In the absence of applicable COC language, medical policy, or technology review, coverage and medical necessity decisions will be based on Medicare coverage criteria. In the absence of Medical Policy for Medicaid, the State of Michigan Medical Services Administration Guidelines will be used.

Review of medical policies
Medical policies are reviewed annually, or more frequently if needed, and approved by the Medical Affairs Committee. This committee is the final approval body if no changes are made to the Medical Policies during the annual review process. Medical Policies that have been revised during the annual review process or are new must be approved by the Medical Affairs Committee.

Priority Health's medical policies can be found in this Provider Manual.