The mission of the Medical Policy Department is to develop and maintain evidence-based coverage guidelines and monitor/assess the medical technology* pipeline to anticipate and plan for the evolution of therapies to ensure appropriate benefit adjudication, patient safety and optimized therapy for our customers.
Highmark is a nationally recognized industry leader in developing and implementing up-to-date, medically sound policy guidelines. There are many policy guidelines addressing medical technology, therapeutic procedures, medical equipment and supplies, and behavioral health. Medical policy coverage guidelines are developed and maintained in accordance with all applicable laws and regulations, standards of regulatory and accreditation agencies such as NCQA and the national Blue Cross Blue Shield Association (BCBSA). They are used to administer all Highmark medical-surgical products and various fee schedule products.
In addition to commercial products, we also maintain medical policy coverage guidelines for our Medicare Advantage products. The Centers for Medicare and Medicaid Services (CMS) requires that Medicare Advantage insurers use CMS national policy and the regional Medicare Part B Carrier's local policy for Medicare Advantage products.
*Medical technology includes any intervention or service to treat any medical/surgical condition. These technologies may include drugs, devices, procedures and/or gene therapy.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.