Medical Payment Guidelines

Virginia Premier has developed medical policies that serve as guidelines for coverage decisions and assist with administering plan benefits. The policies express Virginia Premier’s determination of whether certain services are medically necessary, and they are based upon a review of currently available clinical information. These peer reviewed policies are used when no specific guidelines for coverage are provided by the Department of Medical Assistance Services of Virginia (DMAS) or by the Center for Medicare and Medicaid Services (CMS).  Medical policies are not a substitute for clinical judgement or for any prior authorization requirements of the health plan.  These policies are not an explanation of benefits. 

Medical policies can be highly technical and complex and are provided here for informational purposes. These medical policies are intended for use by health care professionals. The medical policies do not constitute medical advice or medical care. Treating health care professionals are solely responsible for diagnosis, treatment and medical advice. Virginia Premier members should discuss the information in the medical policies with their treating health care professionals.

Medical technology is constantly evolving and these medical policies are subject to change without notice, although Virginia Premier will notify providers as required in advance of changes that could have a negative impact on benefits. Additional medical policies may be developed from time to time and some may be withdrawn from use.  Medical policies that have become obsolete will be archived as appropriate. The medical policies generally apply to all Virginia Premier’s plans, although some variations may exist by plan type. Members may contact customer services representative for specific coverage information.