What Are Medical Policies?

Medical policies serve as one set of guidelines for determining what medical services, procedures, devices and drugs may be eligible for coverage. 

View our alphabetical listing of Medical Policies or use the search function. You also can view the Authorization Table to determine when to request a pre-service review.

InterQual® criteria is used to evaluate whether a medical procedure or equipment is medically necessary. Contracting practitioners can view InterQual criteria via SmartSheets^TM . DME providers and out-of-state providers can receive the SmartSheets via fax by calling 800-552-3993.

Medical Policies are Based on Proven Merits and Scientific Evidence 

Wellmark bases its medical policies on:

• Data from peer-reviewed scientific literature
• Criteria developed by specialty societies
• Guidelines adopted by other health care organizations

Wellmark evaluates medical technologies based on the following criteria:

• The technology must have final approval from the appropriate governmental regulatory bodies
• The scientific evidence must permit conclusions concerning the effect of technology on health outcomes
• The technology must improve the net health outcomes
• The technology must be as beneficial as any established alternatives
• The improvement must be obtainable outside the investigational settings

To request Wellmark’s consideration of a new technology, i.e., biologic, drug, procedure, or device, or new use of an existing technology, please download the technology assessment form .

Providers may send scientific evidence for consideration by the Wellmark medical policy research and development team to policym@wellmark.com.

Network Providers Contribute, Too

When appropriate, Wellmark staff consults with practicing physicians who are members of Wellmark’s team of Medical Policy Advisory Consultants, and other practicing physicians within our provider networks.   

Changes to Medical Policies

Medical technology is constantly evolving and these medical policies are subject to change without notice, except as required by law. Additional medical policies may be developed from time to time and some may be withdrawn from use.

Medical policies designated as “Active Policy; No Longer Scheduled for Routine Literature Review” are used to process claims, but are not subject to Wellmark’s annual literature review.

Wellmark's medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and are not offers of coverage or medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies are subject to change without notice.