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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.


Medical Policies

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.

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.

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 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

This document provides a summary of customizations to the MCG Care Guidelines 27th Edition (Publish date November 17, 2023).
Customizations to MCG Care Guidelines 27th Edition


Carelon Medical Benefits Management

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 Benefits Management. Updates to these guidelines can be found on their website.

By clicking on the link below, you are now leaving our site and linking to a site created and/or maintained by Carelon Medical Benefits Management ("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.
 

Carelon Medical Benefits Management Guidelines


CarelonRx

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.

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To see a list of all Medical Policies and Clinical UM Guidelines, visit our Full List page.

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Acknowledgement

Medical Policies

We have developed medical policies that serve as one of the sets of guidelines for coverage decisions. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the medical policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Medical policy does not constitute plan authorization, nor is it an explanation of benefits.  
 
Medical policies can be highly technical and complex and are provided here for informational purposes. The medical policies do not constitute medical advice or medical care. Treating health care professionals are solely responsible for diagnosis, treatment and medical advice. Members should discuss the information in the medical policies with their treating health care professionals.  
 
Medical technology is constantly evolving and these medical policies are subject to change without notice, although we will use good faith efforts to provide advance notice of changes that could have a negative impact on benefits. Additional medical policies may be developed from time to time and some may be withdrawn from use. The medical policies generally apply to all of the Plan’s fully-insured benefits plans, although some local variations may exist. Additionally, some benefit plans administered by the Plan such as some self-funded employer plans or governmental plans, may not utilize the Plan’s medical policy. Members should contact their local customer service representative for specific coverage information. 
 
The doctors, hospitals, and other providers which are part of the network of providers referred to in this document are independent contractors who exercise independent judgment and over whom we have no control or right of control. They are not agents or employees of the Plan. 
 
If you would like to request a hard copy of an individual medical policy, please contact the member's health plan at the number on the back of their identification card.  

Clinical UM Guidelines  

We have developed clinical UM guidelines that serve as one of the sets of guidelines for coverage decisions.  We are also licensed to use MCG guidelines to guide utilization management decisions. This may include but is not limited to decisions involving pre-certification, inpatient review, level of care, discharge planning and retrospective review. The MCG guidelines we are licensed to use include ((1) Inpatient & Surgical Care (ISC), (2) General Recovery Care (GRG), (3) Recovery Facility Care (RFC), (4) Chronic Care (CC) and (5) Behavioral Health Care Guidelines (BHG). We also have the right to customize MCG guidelines based on determinations by the Medical Policy & Technology Assessment Committee (MPTAC).  
 
Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the clinical UM guidelines. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. A clinical UM guideline does not constitute plan authorization, nor is it an explanation of benefits.  
 
Clinical UM guidelines can be highly technical and complex and are provided here for informational purposes. These guidelines do not constitute medical advice or medical care. Treating health care providers are solely responsible for diagnosis, treatment and medical advice.  Members should discuss the information in the clinical UM guideline with their treating health care providers. 
 
The clinical UM guidelines published on this web site represent the clinical UM guidelines currently available to all health plans throughout our enterprise.  These guidelines address the medical necessity of existing, generally accepted services, technologies and drugs.  Because local practice patterns, claims systems and benefit designs vary, a local plan may choose whether to implement a particular clinical UM guideline.  While the clinical UM guidelines developed by us are published on this web site, the licensed standard and customized MCG guidelines are proprietary to MCG and are not published on the Internet site.  
 
Medical technology is constantly evolving and clinical UM guidelines are subject to change without notice.  Additional clinical UM guidelines may be developed from time to time and some may be withdrawn from use.  Members should contact their local customer service representative for specific coverage information.  
 
The doctors, hospitals, and other providers which are part of the network of providers referred to in this document are independent contractors who exercise independent judgment and over whom we have no control or right of control.  They are not agents or employees of the Plan. 
 
If you would like to request a hard copy of an individual clinical UM guideline or MCG guideline, please contact the member's health plan at the number on the back of their identification card.

 

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