Baptist Health Plan Coverage Criteria
- Baptist Health Plan medical coverage criteria and Policy documents are developed to assist in administering plan benefits and do not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any questions related to their coverage or condition with their treating provider.
- Even though the medical coverage criteria and Policy documents may conclude that a particular service or supply is considered covered, this conclusion is not based upon the terms of your particular benefit plan. Each benefit plan contains its own specific provisions for coverage and exclusions. Not all benefits that are determined to be medically necessary will be covered benefits under the terms of your benefit plan. You need to consult the terms of your own benefit plan to determine if there are any exclusions or other benefit limitations applicable to the particular service or supply. If there is a discrepancy between a Policy and your plan of benefits, the provisions of your benefits plan will govern. However, applicable state mandates will take precedence. Unless otherwise specifically excluded, Federal mandates will apply.
- Since medical coverage criteria and Policy documents can be highly technical and are designed to be used by our professional staff in making coverage determinations, members should review these with their providers so they may fully understand our policies.
- While medical coverage criteria and Policy documents are used as a guide, coverage decisions are made on a case-by-case basis. In the event that a member disagrees with a coverage determination, Baptist Health Plan provides its members with the right to appeal the decision; in addition, a member may have an opportunity for an independent external review based on medical necessity.
- At this time, medical coverage criteria and Policy documents available at this site represent a small portion of coverage policies maintained by Baptist Health Plan
Please give us a call at 800.787.2680 if you have any questions.