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.
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:
This document provides a summary of customizations to the MCG Care Guidelines 24th Edition (Publish date January 20, 2021).
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.
AIM guidelines applicable to Plan programs are maintained by AIM Specialty Health. Updates to these guidelines can be found on their website.
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.
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.
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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