Medical Policies

Preauthorization for acute inpatient care, long term acute care hospital (LTACH), select procedures and select behavioral health services will be conducted using Change Healthcare's InterQual® criteria. InterQual criteria are an industry standard set of objective evidence-based utilization management (UM) criteria for level of care placement and medical necessity determinations, including length of stay. These criteria are specific and comprehensive clinical guidelines developed by a highly trained clinical team who performs unbiased, systematic review and clinical appraisal of the evidence to help ensure the criteria reflect the best available clinical evidence. The criteria are updated frequently to remain current with the latest evidence.

Preauthorization for select substance use disorder services will be performed using the American Society of Addiction Medicine (ASAM) criteria.

ASAM criteria are an industry standard collection of guidelines for level of care placement and medical necessity determinations, including length of stay for substance use disorder services.

Find the medical policy you need in the library below. If medical policy is not located, please refer to the list of specialized services to confirm if medical necessity review is needed.

For specialized services administered by independent companies on behalf of Capital Blue Cross:

You can also view the retired medical policies and out-of-area medical policies.

Specialty Injectables:

For more information about Specialty Injectable drugs, view our list of policies. Specialty Injectable drugs may require preauthorization. Providers, please refer to the single source preauthorization list. Some drugs may also have site of service requirements, please refer to the Drug Infusion Site of Service policy for guidance.

Specialty Injectable preauthorization forms are available for download in your secure provider library when electronic submission is unavailable.

Nonparticipating providers can also access forms and other commonly used resources when needed.

Medicare Information:

For additional Medicare coverage and policy information, please review the Medicare Medical Policy page.

Medical Policy Library (Choose a Letter)

    Complementary Content
    ${loading}