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 member's benefit coverage. Blue Cross Blue Shield of Massachusetts doesn't reward doctors or other individuals for denials of coverage in any way. We offer no financial incentives to encourage decisions that result in underutilization of care and services.

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.

This information is intended for reference purposes only. Please consult your doctor with any questions regarding clinical criteria.

Clinical Review Criteria

For more information about what technology, procedure, treatment, supply, equipment, drug, or other service we'll cover, please visit our Medical Policies.

If you do not find what you're looking for in the search results of Medical Policies, you can 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. Don't use this form to request coverage of any services, or to request authorization for services.