Medical policies

Wellpoint specifically excludes coverage for services or supplies it determines to be investigational and/or not medically necessary. Wellpoint follows all medical policies, clinical criteria, and certain adopted clinical UM guidelines, and processes claims in accordance with these determinations.

Prepayment review – Clinical guidelines approved by the Medical Policy and Technology Assessment Committee, but not included in the standard adopted list, may be used to review a provider's claims. This may occur when a provider's billing practices are not consistent with other providers in terms of frequency or in some other manner. It may also occur when there is a need for provider education. In such instances, the clinical guidelines used for review of these providers are "adopted" for those indicated purposes.

To view our policies and guidelines, visit Medical policies and clinical UM guidelines.