Medical Policy Frequently Asked Questions (FAQs)

Q. What is "Medical Policy"?

Medical policies are documents that provide medical necessity and coverage guidelines for all of our medical-surgical products.

Q. Who is the Medical Policy Department?

The Medical Policy Department is a department within the Medical & Payment Policy Administration Division. The department is responsible for the development and maintenance of all medical policy for our medical-surgical contracts.

Q. How are services, drugs, devices, and supplies determined to be experimental or investigational?

Services, drugs, devices, and supplies are determined to be experimental or investigational based on:

  • advice of the general medical community, including medical consultants, medical journals, and publications,
  • applicable governmental regulations, such as FDA approval,
  • available scientific evidence which doesn't permit conclusions concerning the effect on health outcomes,
  • when the service isn't proven to be as safe or effective as alternative treatment or when the service doesn't improve health outcomes, or
  • when the service isn't proven to be outside the research setting.

Q. What, in general, do medical policies address?

Medical policies address hundreds of issues, such as anesthesia services, consultations, durable medical equipment and supplies, pathology, diagnostic medical services, radiology, nuclear medicine, surgery, cosmetic versus reconstructive surgery, maternity services, therapies, and evaluation and management services. Medical policies also address which services are considered to be experimental/investigational, global, bundled/unbundled, procedures of current questionable usefulness, and services that are considered to be an integral part of a primary service.

Q. Do your medical policy evaluations of new technology and new uses of existing technology meet NCQA requirements?

Yes. We meet and/or exceed all of NCQA's stringent criteria for our technology evaluations.

Q. What is the role of medical policy in relationship to benefits?

Medical policy is intended to further define and enhance a Member's benefits. For example, most benefits do not cover experimental/investigational services. Through our technology evaluations, medical policy determines what services are considered to be experimental/investigational.

Q. How are Highmark medical policy issues communicated to health care professionals?

Medical policy issues are communicated to health care professionals through our monthly publication, Medical Policy Update. If you have questions or comments on new medical policy issues in a particular edition, please e-mail us at

Q. Are any actively practicing health care professionals involved in the medical policy development process?

Yes. We utilize a panel of approximately 280 actively practicing health care professionals as Professional Consultants who provide input into the development of medical policy guidelines. In addition to our Consultants, we also utilize other resources such as CMS (Centers for Medicare and Medicaid Services) and Blue Cross Blue Shield Association (BCBSA) guidelines, input from various state and national specialty societies, and current published medical literature.

Q. What is the role of the Professional Consultants?

Professional Consultants provide input in the development of our medical policy, help establish recommended fees, and provide claim and utilization reviews.

Q. Can I become a Professional Consultant?

If you are a network health care professional, practicing in Pennsylvania, and are board certified in your specialty, you can submit a request, along with your resume and curriculum vitae, to:

Medical Policy

1800 Center Street
Camp Hill, Pennsylvania 17011

Last updated on 10/19/2017


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