Clinical Criteria:  Hierarchy and Guidelines

Our Utilization Management (UM) review process utilizes criteria, which is compliant with Medicare and relevant Medicaid requirements, to assist in determinations of benefit coverage, behavioral health needs and medical appropriateness.  

Every year, the criteria used is reviewed and approved by the UM Committee. 

Following applicable federal and state guidelines, where applicable, the following hierarchy is observed when making clinical determinations:

• CMS National Coverage Determination (NCD)

• Local Coverage Determination (LCD)

• Local Coverage Articles (LCA)

• CMS Manuals

Medicare Approved Drug Compendia/Medicare Benefit Policy Manual Ch 15 Section 50.4 and sub-chapters for anti-cancer chemotherapy regimen drugs (50.4.5) and immunosuppressive drugs (50.5.1) and Specific Guidelines for Part B Drug Step Therapy or organization Specific Guidelines for Device Preferred Products (for drugs which have not been used within the last 365 days), if applicable:

• Medicare Benefit Policy Manual

• DHCS Medi-Cal Guidelines (if/where applicable)

Health Plan Clinical Policies:

ALIGNMENT HEALTH PLAN — no dedicated CPG page (publishes MCG medical-necessity guidelines only)

ANTHEM BLUE CROSS / ELEVANCE (CALIFORNIA)

• Medi-Cal (CPGs + Preventive Health Care Guidelines are downloadable on this hub)

ASTIVA — no dedicated CPG page (UM criteria only)

BLUE SHIELD of CALIFORNIA / PROMISE HEALTH PLAN

• Medi-Cal

• Medi-Medi

• Medicare

BLUE CROSS BLUE SHIELD OF TEXAS

• Medicare

• Medi-Medi

• C-SNP

CENTRAL HEALTH / MOLINA

• Medi-Medi

• Medicare

• C-SNP

CHAMPION HEALTH — no dedicated CPG page (portal-gated)

CLEVER CARE HEALTH PLAN

• Medicare

• C-SNP

HEALTH NET OF CALIFORNIA (CENTENE) — CPGs are on the provider portal (login); public reference below

• Medi-Cal

• C-SNP

• Medicare

• Medi-Medi

MOLINA HEALTH PLAN

• Medi-Cal

• Medi-Medi

• Medicare

• C-SNP

• Covered CA

• Commercial

SCAN HEALTH PLAN OF ARIZONA

• Medi-Medi

• Medicare

• C-SNP

SCAN HEALTH PLAN OF TEXAS

• Medi-Medi

• Medicare

• C-SNP

SUPERIOR CHOICE HEALTH PLAN / WELLCARE (TEXAS)

• Medi-Medi

• Medicare

• C-SNP

VERDA HEALTH PLAN (ARIZONA) — no dedicated CPG page (UM program & criteria only)

VERDA HEALTH PLAN (TEXAS) — no dedicated CPG page (UM program & criteria only)

WELLCARE / CENTENE / HEALTH NET (CALIFORNIA) — CPGs on the provider portal (login); public reference below

• Medi-Medi

• Medicare

• C-SNP

WELLPOINT (TEXAS) — no separate CPG page; folded into the medical-policies/clinical-guidelines hub

• Medi-Medi

• Medicare

• C-SNP

Milliman Care Guidelines (MCG): 

• Alignment Health Plan

• Central Health Plan/Molina Healthcare

• SCAN Health Plan