There are several factors that impact whether a service or procedure is covered under a member’s beneﬁt plan. Medical policies and clinical utilization management (UM) guidelines are two resources that help us determine if a procedure is medically necessary. These guidelines are available to you as a reference when interpreting claim decisions.
Medical Policies are used by all plans and lines of business unless Federal or State law—as well as contract language, including definitions and specific contract provisions or exclusions—take precedence over a medical policy. Those provisions will be considered first in determining eligibility for coverage before the medical policy is used to determine medical necessity.
The Clinical UM guidelines published on this website are not always used by all plans or lines of business. Clinical UM guidelines are available for adoption to review the medical necessity of services related to the guideline when the Plan performs a utilization review for the subject. Because practice patterns, claims systems and benefit designs vary, a local plan may choose whether to adopt a particular clinical UM guideline.
Health plans or lines of business which determine there is not a need to adopt a clinical utilization management guideline may instead use the guideline for educational purposes or to review the medical necessity of services for any provider who has been notified that his or her claims will be reviewed due to billing practices or claims that are inconsistent with other providers.
To determine which clinical utilization management guidelines have been adopted by your plan, or to determine if there are applicable other criteria, you can use the guideline adoption link provided below.
In addition to the documents we develop and maintain for coverage decisions, we may adopt criteria developed and maintained by other organizations. Note that where we have developed a medical policy that addresses a service also described in one of these other sets of criteria, the plan’s medical policy supersedes.
InterQual Level of Care (LOC) criteria is used by some Medicaid plans for medical necessity review for medical inpatient concurrent review, inpatient site of service appropriateness, home health and outpatient rehabilitation. The InterQualTM guidelines licensed include:
MCG care guidelines are licensed and utilized to guide utilization management decisions for some health plans. This may include but is not limited to decisions involving prior authorization, inpatient review, level of care, discharge planning and retrospective review. MCG guidelines licensed include:
Our health plans may use guidelines developed by Carelon Medical Benefits Management, Inc. to perform utilization management services for some procedures and certain members.
Carelon Medical Benefits Management guidelines applicable to Plan programs are maintained by Carelon Medical Benfits Management. Updates to these guidelines can be found on their website.
CarelonRx is an independent company providing pharmacy benefit management services on behalf of the plan. Clinical criteria for drugs and biologics paid under the medical benefit for certain Medicare/Medicaid markets can be found on the CarelonRx website.
The pharmacy clinical criteria for injectable, infused or implanted prescription drugs and therapies covered under the medical benefit are available for certain Medicare/Medicaid markets.
There are several different dates that may be associated with a medical policy or clinical utilization management guideline
Publish Date — the date a medical policy or clinical UM guideline was made available on our public websites
Last Review Date — the date a medical policy or clinical UM guideline was reviewed and approved
Note that while a publish date is enterprise-wide, the implementation date may differ depending on notification requirements. Please refer to the plan Provider Newsletter for more information relating to implementation dates.
If a medical policy or clinical UM guideline is not yet implemented for your Plan, historical versions may be accessed.
Please contact us with inquiries.
To see a list of all Medical Policies and Clinical UM Guidelines, visit our Full List page.
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