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 23rd Edition (Publish date November 1, 2019).
Customizations to MCG Care Guidelines 23rd Edition
This document provides a summary of customizations to the MCG Care Guidelines 24th Edition (Publish date June 26, 2020).
Customizations to MCG Care Guidelines 24th 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 that may be adopted for use include:
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.
Please contact us with inquiries.
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