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MANUALS, POLICIES & GUIDELINES

Manuals, Policies & Guidelines

Review the latest provider administration manuals, medical policies and guidelines to find information about how we deliver member benefits, how we determine medical necessity and other important decisions.

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PROVIDER ADMINISTRATION MANUALS

View our Provider Administration Manuals

As discussed in our provider contracts, these manuals are your source for important information about our policies and procedures.

We’ve dedicated a COVID-19 Provider FAQ at BCBSTupdates.com for temporary policy changes related to claims, coding, enrollment and other policy changes during the COVID-19 emergency. That FAQ takes precedence over any information that may conflict with information in our current PAMs during this COVID-19 emergency. Please contact your network manager if you have questions.

Please note, the updated PAMs are effective on the first day of the new quarter. Effective dates are as below:
Quarter 1: Jan. 1
Quarter 2: April 1
Quarter 3: July 1
Quarter 4: Oct. 1

Commercial PAM (Preview Edition Effective April 1, 2023)

Commercial Provider Administration Manual (including Medicare Advantage)

BlueCare Tennessee Provider Administration Manual

BlueCare Tennessee Provider MLTSS Manual

BlueCare Tennessee Community Living Supports Manual for CHOICES and ECF CHOICES

BlueCare Plus (HMO SNP)℠ Provider Administration Manual

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Behavioral Health Levels of Care

We’re dedicated in offering specialized guidance to ensure members get the right care, at the right time.
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See our coverage policies & guidelines
Find more information about our medical policies, utilization management guidelines and administrative services policies. You can also see newly approved policies and guidelines, and offer feedback on developing policies and updates.
MCG Cite Guideline Transparency
Medical Policies
Utilization Management Guidelines
Administrative Services Policies
Telehealth Guidelines
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BlueCross BlueShield of Tennessee Clinical Practice Guidelines

BlueCross adopts and disseminates specific nationally recognized clinical practice guidelines for use by our network providers. The guidelines address acute and chronic medical services, and behavioral health services to assist Practitioners in making appropriate health care decisions for specific clinical circumstances. It’s our intent to make resources available to our providers that will help in this endeavor. BlueCross attests that the text and format of these compendia have not been altered in any way, and that these resources should not be construed as a legal or required standard of care.

More information can be found in the U.S. Preventive Services Task Force Guide to Clinical Preventive Services. We hope this will be both convenient and helpful to you in caring for your patients. Paper copies of the guidelines are available upon request by calling (423) 535-6705(423) 535-6705.

Behavioral Health CPGs
Service Resource(s) Last Reviewed / Approved
ADHD (Pediatric) 2014 American Academy of Family Physicians (AAFP) Diagnosis and Management of ADHD in Children (Last reviewed 1/2023)
Autism (Pediatric) 2020 American Academy of Child & Adolescent Psychiatry (AACAP) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Autism Spectrum Disorder (Last reviewed 1/2023)
Eating Disorders (Pediatric) 2015 American Academy of Child Adolescent Psychiatry (AACAP) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Eating Disorders (Last reviewed 1/2023)
Depression 2022 Veteran’s Affairs/Department of Defense (VADoD) Clinical Practice Guideline for the Management of Major Depressive Disorder (Last reviewed 1/2023)
Substance Abuse 2020 Substance Abuse and Mental Health Services Administration (SAMHSA) A Treatment Improvement Protocol: Substance Abuse Treatment and Family Therapy (Last reviewed 1/2023)
Medical CPGs
Service Resource(s) Last Reviewed / Approved
Asthma 2007 National Heart, Lung, and Blood Institute (NIH) EPR-3 Guidelines for the Diagnosis and Management of Asthma (includes: 2008 edits to the 2007 guideline) Last reviewed 7/2022
Back Pain 2017 American College of Physicians (ACP) Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline Last reviewed 11/2022
Bright Futures™ (Pediatrics) 2017 Bright Futures™ Guidelines for Prevention and Health Promotion for Infants, Children, Adolescents, and their Families – Forth Edition (The 2017 Bright Futures™/American Academy of Pediatrics Periodicity Schedule Recommendations are listed on the home page menu) Last reviewed 11/2022
Cardiovascular Risk 2013 Report of the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines: Guideline on the Assessment of Cardiovascular Risk Last reviewed 7/2022
COPD 2018 Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease Global Obstructive Lung Disease (GOLD); Report Last reviewed 7/2022
Cholesterol 2013 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA); Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults Last reviewed 7/2022
Diabetes 2022 American Diabetes Association®(ADA); Standards of Medical Care in Diabetes Last reviewed 7/2022
Heart Failure 2013 American College of Cardiology Foundation(ACCF)/American Heart Association (AHA); and 2017 ACCF/AHA/Heart Failure Society of America (HFSA) Focused Update for: Guideline for the Management of Heart Failure: A Report of the ACCF/AHA Task Force on Practice Guidelines Last reviewed 11/2022
HTN 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) Last reviewed 11/2022
Immunizations 2021 Center for Disease Control & Prevention; Recommended Immunization Schedules: For Healthcare Professionals: Child, Adolescent & Catch-up Last reviewed 7/2022
Obesity 2013 National Institute of Health; Managing Overweight and Obesity in Adults: Systematic Evidence Review from the Obesity Expert Panel Last reviewed 7/2022
Prenatal 2018 American College of Obstetricians and Gynecologists; Guidelines for Perinatal Care, Eighth Edition. Available for Purchase. Last reviewed 7/2022
Perinatal 2012 American Academy of Pediatrics (AAP) and American College of Obstetrics and Gynecology (ACOG) Guidelines for Perinatal Care, 7th Edition Last reviewed 7/2022
Non ST-Elevated MI 2014 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes Last reviewed 11/2022
Rheumatoid Arthritis 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis (Last reviewed 1/2023)
ST-Elevated MI 2013 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Guideline for the Management of ST-Elevation Myocardial Infarction & 2015 ACC/AHA Focused Update & 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction (Last reviewed 11/2022)
Stroke 2018 American Heart Association/American Stroke Association; Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals Last reviewed 11/2022
USPSTF Guide to Clinical Preventative Services U.S. Preventive Services Task Force [USPSTF] Recommendations (Last reviewed 1/2023)
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