Utilization Management

We believe that doctors and hospitals should deliver high-quality patient care and help to keep members healthy.

Our utilization management decisions are based only on the appropriateness of care and the full extent of a member's benefit coverage. Blue Cross Blue Shield of Massachusetts does not reward doctors or other individuals for denials of coverage in any way. We offer no financial incentives to encourage decisions that result in health plan underutilization.

Utilization Management uses evidence-based clinical criteria to ensure that the highest quality medical care is provided within the benefit limit, and that practices are observed that make this care as affordable as possible to our members.

The clinical criteria we use to make medical necessity determinations are developed with input from practicing clinicians in relevant specialties and are based on clinical evidence. We review the criteria annually.

Please note: This information is intended for reference purposes only. Please consult your doctor with any questions regarding these criteria. For more information about other services not listed here, please refer to our Medical Policies.

Behavioral Health:

Medical:

Clinical Review Criteria

Complete the Request for Clinical Criteria form to receive a copy of the criteria used to determine what is included in your coverage of services. Instructions to submit your request are at the bottom of the form.

Please note: This Request for Clinical Criteria form is solely for criteria requests. Do not use this form to request coverage of any services, or to request authorization for services.