Medical Policies and Clinical
UM Guidelines
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.
About Medical Policies & Clinical UM Guidelines
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.
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.
Clinical UM Guidelines
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.
Other Criteria
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
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:- Inpatient & Surgical Care
- General Recovery Care
- Recovery Facility Care
- Chronic Care
- Behavioral Health Care
Customizations to MCG Care Guidelines
This document provides a summary of customizations to the MCG Care Guidelines 23rd Edition (Publish date November 1, 2019).
Customizations to MCG Care Guidelines 23rd Edition
AIM Specialty Health (AIM)
Our health plans may use guidelines developed by AIM Specialty Health (AIM) to perform utilization management services for some procedures and certain members. AIM guidelines that may be adopted for use include:
- Clinical Appropriateness Guidelines for Radiology (adult and pediatric)
- Clinical Appropriateness Guidelines for Sleep Disorder Management
- Musculoskeletal Clinical Appropriateness Guidelines: spine surgery, joint surgery, and interventional pain management
- Level of Care Guidelines for Musculoskeletal Surgery and Procedures
- Preoperative Admission Guidelines for Musculoskeletal Surgery and Procedures
- Cardiology Clinical Appropriateness Guidelines: advanced imaging of the heart, arterial ultrasound, percutaneous coronary intervention, and diagnostic coronary angiography
- Radiation Oncology Clinical Appropriateness Guidelines: brachytherapy, intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), and stereotactic radiosurgery (SRS)
By clicking on the link to AIM below, you are now leaving our site and linking to a site created and/or maintained by AIM ("External Site"). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Site. We provide this link solely for your information and convenience. We encourage you to review the privacy practices of the External Site. The information contained on the External Site should not be interpreted as medical advice or treatment provided by us.
IngenioRx
IngenioRx, Inc. 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 IngenioRx 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.
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.
Associated Dates
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.
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.
Contact Us
Please contact us with inquiries.
Search by keyword or code
To see a list of all Medical Policies and Clinical UM Guidelines, visit our Full List page.