Medical Necessity Criteria and Clinical Review Guidelines
Care Management uses nationally recognized and accepted utilization management criteria, as well as internally developed policies, guidelines and protocols for medical necessity determination. All criteria are annually reviewed and updated as necessary.
Simply access the criteria that match the service type that you will be providing by choosing the appropriate link, located below. Please contact the Care Management telephone number on the back of the member's identification card should you have any questions.
Criteria Type
- Medical Policies provide guidelines for determining coverage for specific procedures, therapies, devices, equipment and services.
- MCG provides guidelines for determining coverage for inpatient care as well as specific procedures, devices, equipment and services.
- Go here for Therapy/Chiro and Radiology/Imaging codes that require prior authorization.
- Go here for information on Review Criteria.
- For Rad/Onc: Select Radiation Oncology