Medical Policies
Preauthorization for acute inpatient care, long term acute care hospital (LTACH), select procedures and select behavioral health services will be conducted using Change Healthcare's InterQual® criteria. InterQual criteria are an industry standard set of objective evidence-based utilization management (UM) criteria for level of care placement and medical necessity determinations, including length of stay. These criteria are specific and comprehensive clinical guidelines developed by a highly trained clinical team who performs unbiased, systematic review and clinical appraisal of the evidence to help ensure the criteria reflect the best available clinical evidence. The criteria are updated frequently to remain current with the latest evidence.
Preauthorization for select substance use disorder services will be performed using the American Society of Addiction Medicine (ASAM) criteria.
ASAM criteria are an industry standard collection of guidelines for level of care placement and medical necessity determinations, including length of stay for substance use disorder services.
Find the medical policy you need in the library below. If medical policy is not located, please refer to the list of specialized services to confirm if medical necessity review is needed.
For specialized services administered by independent companies on behalf of Capital Blue Cross:
- High Tech Radiology including Cardiac Imaging and Radiation Oncology
- Laboratory Services
- Molecular Lab Management Services – Effective January 1, 2026, EviCore’s management of preauthorization for outpatient molecular and genomic tests will be expanded to include Capital Blue Cross Administrative Services Only (ASO) members. (select ASO groups excluded). As of November 1, 2025, EviCore began managing these services for Commercial Fully Insured, CHIP, and Medicare Advantage members.
- Musculoskeletal policies including hip, knee, shoulder and spine related services
- Select Diagnostic and Surgical Cardiology Services
You can also view the retired medical policies and out-of-area medical policies.
Specialty Injectables:
Effective January 1, 2026, Prime Medical Pharmacy Solutions1 (Prime MPS) will manage services related to specialty medical injectable drugs, on behalf of Capital.
Specialty injectable drugs may require preauthorization through Prime MPS. Please refer to the single source preauthorization code list. Additionally, some drugs may have a site of service requirement.
To learn more about coverage criteria, including Drug Infusion Site of Service requirements, you may access Prime’s medical drug policies.
1On behalf of Capital Blue Cross, Prime Medical Pharmacy Solutions (Prime MPS), a division of Prime Therapeutics Management LLC an independent company, provides medical specialty drug management services.
Medicare Information:
For additional Medicare coverage and policy information, please review the Medicare Medical Policy page.
Medical Policy Library (Choose a Letter)
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