Medical Policy Department
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, and medical equipment and supplies. 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.