How Are Medical Policies Developed?

Medical policy guidelines have their foundation in our customers' health care agreements (i.e. contracts) with Highmark. Two of the most important provisions in all those contracts are a medical necessity clause and the exclusion of coverage for experimental/investigational procedures. Policies are established and maintained to address these provisions for a variety of procedures.

Our policies are based on substantial professional input, including:

  • a system of about 280 Professional Consultants who provide us with current expert information
  • current medical literature, including the published results of clinical studies
  • FDA or other regulatory approval where applicable
  • state and national professional organizations (such as the Pennsylvania Medical Society or the American Medical Association) which provide us with position papers
  • guidelines from national organizations such as CMS (Centers for Medicare and Medicaid Services) and the Blue Cross Blue Shield Association 

Highmark's medical policy guidelines have been integrated into our claims processing system, which allows for cost-effective claims processing and ensures consistent, accurate administration of our customers' health care benefits.

Last updated on 10/4/2021 4:56:31 PM


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