Clinical Guideline Criteria

Blue Cross Community MMAI (Medicare-Medicaid Plan)SM uses Medicare and internal medical policies to make sure that you can get the best health care.

How Does Blue Cross Community MMAI Use Clinical Guidelines to Make Decisions for Prior Authorizations?

Doctors use evidence-based clinical guidelines to make sure you get the health care you need. All criteria used is based on scientific and medical research.

Coverage Decisions

Our clinical team applies clinical guidelines to make sure you are getting safe and necessary care. There are no rewards to deny or promote care.

Always talk to your doctor about any health questions or concerns. You can also check with your doctor if you have questions about prior authorization or medical policies. 

Use the links below to review Blue Cross Community MMAI and vendor guidelines that may apply.

  • Blue Cross Community MMAI Medical Policies
  • eviCore
    • From the Clinical Guidelines page linked above; choose the category that best fits your needs.
    • Choose to accept the pop up to allow access to the information
    • In the search bar type the name of your plan:
      • Use the format below to easily find your information based on your plan:
        • BCBS IL - Medicaid/Medicare
    • If there is information for your plan in this category, you will find it here.
  • Blue Access for Members
    • Log in to BAM to access the MCG Care Guidelines website

If you want to know more about the utilization management process or how decisions are made about your care, Contact Us.