Blue Promise: Clinical Policy vs. Medical Policy

Do you have a hard time understanding medical policies and clinical policies that impact your coverage? This Blue Promise may help!

Educated health care consumers make better decisions about when, where and how they get care. But understanding the details of medical billing can be confusing!  In this Blue Promise, Dr. McCoy explores the differences between clinical policies and medical policies.

Blue Promise is an online video blog that aims to address complicated health issues with candid conversations from subject matter experts. New editions are published regularly and are hosted by Dr. Dan McCoy, President of Blue Cross and Blue Shield of Texas.


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  • It is really frustrating to call the number on the back of my card or the pre-authorization department with questions about a medical policy and almost NO ONE knows what they are or how they get attached to an pre-authorization. I was told "Let me explain this to you in a way you can understand. Medical Policies are like when you buy a canned good in the store. The cans look the same but when the machine scans them the bar codes are different. They aren't something you can go read, they are just a policy number." This was a supervisor. I have discovered that once an incorrect Medical Policy is attached, no one looks inside the policy to see if it matches the procedure and everyone just wants to tell me how "I" don't know what I'm talking about. My doctor's office has called, 2 peer to peers were done, however, the doctor who completed the second peer to peer never spoke to anyone at my doctor's office and it is documented in the denial. It seems to me a review of an appeal would include opening the medical policy and verifying that it matches all the procedure codes the doctor used in the pre-authorization paperwork. No one can tell me how and when the wrong medical policy was attached (I HAVE A COPY OF THE ORIGINAL REQUEST AND IT DID NOT COME FROM MY DOCTOR - so frustrated hearing that over and over).  How do I get someone with the power to do something about this? The few people who were willing to read the policies saw the error but they tell me all they can do is pass it on. I can be sure I will never get past this error for a fair appeal until I talk to someone who makes the decisions. What I am trying to explain is not getting through to them as someone actually read the notes back to me and it said the error was made by the doctor. These procedure codes were approved for the trial and are approved for the procedure I need but they are useless without the implant. Seems pretty useless to perform a procedure with nothing to implant. An implant with the same code was approved and is now being denied. In the meantime, I am in constant pain which is not controlled by any other means. This makes it doubly hard on me since the trial implant was 85 to 90% effective and I was almost pain free, could walk through a store without having to sit on the floor, could take a shower, work, clean my home, etc. It is really cruel to approve the trial and have it work so well only to deny the final procedure due to an incorrect medical policy that no one will read!!!