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

• Central Health Plan/Molina Healthcare

• HealthNet

• SCAN Health Plan

• WellCare Health Plan

Milliman Care Guidelines (MCG): 

• Alignment Health Plan

• Central Health Plan/Molina Healthcare

• SCAN Health Plan