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 utilization management (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.
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:
Customizations to MCG Care Guidelines 24th Edition
This document provides a summary of customizations to the MCG Care Guidelines 25th Edition (Publish date August 19, 2021).
Customizations to MCG Care Guidelines 25th Edition
This document provides a summary of customizations to the MCG Care Guidelines 26th Edition (Publish date December 9, 2022).
Customizations to MCG Care Guidelines 26th Edition
Our health plans may use guidelines developed by AIM Specialty Health (AIM) to perform utilization management services for some procedures and certain members.
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.
To see a list of all Medical Policies and Clinical UM Guidelines, visit our Full List page.
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