For certain member contracts, the Health Plan has delegated utilization management of the following services to eviCore Healthcare MSI, LLC d/b/a eviCore Healthcare: implantable cardiac devices, radiology/imaging, radiation therapy, and musculoskeletal services (large joint replacement, pain management, and spine services). The Health Plan has adopted eviCore’s medical policies and guidelines as a basis for the determination of medical necessity and appropriateness of care.
Please refer member-specific questions to the Customer Care number on the back of the member ID card. Final determination of coverage is subject to the member’s benefits and eligibility on the date of service.
|Periodontal Scaling and Root Planing Open a PDF 13.01.04||2022-07-15||Dental|
|Periodontal Maintenance Open a PDF 13.01.05||2022-07-15||Dental|
|Dental and Oral Care under Medical Plans Open a PDF 7.01.21||2022-07-15||Dental|
|Dental Inlays and Onlays Open a PDF 13.01.03||2022-07-15||Dental|
|Dental Implants Open a PDF 13.01.01||2022-07-15||Dental|
|Dental Crowns and Veneers Open a PDF 13.01.02||2022-07-15||Dental|
Modal for Medical Policy and Preauthorization Information for Members of Other BlueCross Plans