Clinical Criteria Information

Policy

Evidence based, nationally accepted criteria are utilized when authorizing services. In addition, the members’ needs: age, co-morbidity, complications, home environment, treatment progress and psychosocial situation are also taken into consideration. Application of the criteria shall be based on the needs of individual patients and characteristics of the local delivery system. The criteria utilized is focused on both the inpatient and outpatient services requested.

Procedure

1. The Medical Director shall oversee the application of the criteria. Medical Reviewers make medical necessity determinations based on clinical guideline following: CMS hierarchy, commercial hierarchy, and Medical hierarchy and not based on the member's age, co-morbidities, and progress in treatment, psychosocial situation, home environment, network resources and support system. The decision-making for UM is based only on appropriateness of care and service and existence of coverage. UM decision-making criteria that are objective and based on current medical evidence. Applying criteria based on availability of outpatient services in lieu of inpatient services such as ambulatory surgical centers vs. inpatient surgery. Applying criteria based on availability of highly specialized services, such as transplant facilities or cancer centers. Applying criteria based on availability of skilled nursing facilities, subacute care facilities or home care in the organization’s service area to support the patient after hospital discharge. Apply criteria based on local hospitals’ ability to provide all recommended services within the estimated length of stay. The criteria or guidelines must be consistent with sound clinical principles and processes and must be evaluated at least annually and updated as necessary. IPA may develop proprietary criterion; such criterion requires prior approval from Health Plans Medical Policy Committee prior to use for UM decision-making.
2. Appropriate licensed practitioners are involved in developing, adopting, and reviewing criteria. Reviewed on annual basis or as needed.
3. The use and application of appropriate criteria and all criteria is documented on each IPA website for all UM decisions.
4. Criteria resources include Medi-Cal Guidelines, Medicare Guidelines (CMS) NCD, LCD, MCG Guidelines, Clinical Practice Guidelines and Health Plan guidelines.
5. Hierarchy of Criteria:
   a.   Clinical staff shall apply criteria in the following hierarchy (Medicare):
   i.  Medicare National Coverage Determination (NCD)
   ii.   Medicare Local Coverage Determination (LCD)
   iii.   Medicare Claims Processing Manual
   iv.   CMS Benefit Policy Manual/Medicare Managed Care Manual
   v.   Health Plan Guidelines or Evidence of Coverage
   vi.   MCG Care Guidelines
   vii.   Medicare Program Integrity Manual
   b.   Consideration of the CMS-approved EOB, formulary, appropriate CMS regulations and guidance, required drug compendia, previous claims history, and all submitted clinical information. Making and documenting requests for necessary clinical documentation from providers and prescribers when documentation is needed to properly adjudicate coverage/organization determination requests and appeals. (42 C.F.R. §§ 422.566(a) and (d), 423.562(a) and (d))                                                                                                                          c.   Mental health and Substance Use Disorders MH/SUD American
   i.   Society of addiction Medicine (ASAM) Criteria
   ii.   Level of care utilization system (LOCUS) guidelines
   iii.   Child and Adolescent Level of Care Utilizations (CALOCUS) Guidelines
   iv.   Early childhood service intensity instrument (ECSII) Guidelines
   d.   Clinical staff shall apply criteria in the following hierarchy (DSNP)
   i.   Medicare:
   1.   CMS National Coverage Determination (NCD)
   2.  CMS Local Coverage Determination (LCD)
   3.   CMS Benefit Policy Manual/Medicare Managed Care Manual
   4.   MCG Guidelines
   ii.   Medi-Cal:
   1.   Medi-Cal Guidelines
   2.   MCG Guidelines
   3.   Health Plan Evidence of Coverage (EOC)