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16 11/2005
UM Determinations
Obtaining UM Guidelines
Milliman Care Guidelines are used to assist BCBSGa UM staff in assigning coverage for
length of hospital stay and evaluating the appropriateness of hospital admissions.
The guidelines also help define when hospitalization may not be medically necessary
and, therefore, not covered. Corporate medical policies and guidelines are used for
review of medical appropriateness for select outpatient surgical and radiological
imaging procedures.
Specific UM guidelines used by BCBSGa are available for review by network physicians
upon request and currently include corporate medical policies and guidelines and
Milliman Care Guidelines. Corporate medical policies and guidelines are available on
the provider website at www.bcbsga.com
. Also, you can obtain a copy of a specific
guideline or policy by calling customer care at (800) 241-7475 from 7 AM to 7 PM
weekdays or by sending a written request to the address below and specifying the
guideline or policy of interest, a physician name and the address to which the
guideline should be sent to:
Blue Cross Blue Shield of Georgia
Attention: Prior Approval, Mail Code G00902
3350 Peachtree Road NE
Atlanta, GA 30326
All decisions regarding medical necessity, the appropriateness of care, and
recommendations from the UM staff and supporting medical directors and peer
advisors are based on clinical information and the terms of the Membership
Agreement. Blue Cross Blue Shield Health Plan (BCBSGa) associates, committee
members, and consultants are not compensated for denials or decisions impacting
care or the access to care. There are no performance incentives or rewards for
denials or evaluation tools that encourage or provide any incentives for denials or
inappropriate utilization.