CurrentAnthem Blue Cross and Blue Shield Medicaid (Ohio)Policy N/A

Clinical Utilization Management Guidelines

This document lists Anthem Blue Cross and Blue Shield Medicaid (Ohio Medicaid Managed Care) Clinical Utilization Management (UM) Guidelines and related Medical Policies/Members of criteria titles adopted by the plan (including many CG-, DME-, LAB-, MED-, SURG-, RAD-, ED- entries). It explains use of MCG Care Guidelines and standardized tools for behavioral health and substance use determinations and provides administrative guidance for where policy/UM guidelines apply.

Policy Summary

PayerAnthem Blue Cross and Blue Shield Medicaid (Ohio)

PolicyClinical Utilization Management Guidelines

Policy CodePolicy N/A

Change TypeList/Adoption of Criteria (many items marked New)

Effective Date

Next Review Date

Key ActionIf a request does not meet established criteria/guidelines it will be referred to a licensed physician reviewer with appropriate clinical expertise; determinations are made case-by-case per Medicaid state contract/regulatory/CMS requirements and Anthem Medical Necessity Criteria ADMIN.OO004.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes were reported in this announcement; the brief lists adopted Clinical UM Criteria and notes many items marked as New, but indicates no material change.

100+Listed Criteria Items

2023-09-28Adoption Date for new criteria

1Primary administrative guideline (CG-ADMIN-01)

Policy summary and high-level details

This document is a consolidated listing of Clinical Utilization Management (UM) Guidelines and related Medical Policy titles adopted by Anthem Blue Cross and Blue Shield Medicaid (Ohio). Its purpose is to enumerate the Clinical UM Criteria the plan uses to support appropriate care and to reduce inappropriate use of medical resources. Status: CURRENT; Subject: Clinical Utilization Management Guidelines list/announcement.

The plan relies on MCG Care Guidelines for many utilization management decisions, including medical necessity review for medical and behavioral health inpatient care, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services/procedures when no internal Medical Policy or Clinical UM Guideline exists.

When applicable, standardized behavioral health and substance-use assessment tools are used: LOCUS for adults, CASII for children/adolescents, ECSI for young children, and ASAM criteria for substance use services per state requirements. Where Medicaid state contracts, regulatory guidance, CMS requirements or Anthem Medical Policy/Clinical UM Guidelines (when approved by DMS) apply, those take precedence over external MCG guidance.

Key metadata

PayerAnthem

PolicyClinical Utilization Management Guidelines

Policy CodeN/A

Effective Date

Last Review2023-09-28

Next Review

StatusCURRENT

Scope SummaryThis document lists Anthem Blue Cross and Blue Shield Medicaid (Ohio Medicaid Managed Care) Clinical Utilization Management (UM) Guidelines and related Medical Policies; explains use of MCG Care Guidelines and standardized tools for behavioral health and substance use determinations; and provides administrative guidance for where policy/UM guidelines apply.

Primary administrative guidelineCG-ADMIN-01: Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists

Use of external and internal guidelines for utilization management

The following criteria reflect the Clinical Utilization Management Guidelines and tools Anthem uses to make utilization management and medical necessity determinations. Covered when ALL of the following are met:

ALL of the following

MCG Care Guidelines are used for: medical necessity review for medical and behavioral health inpatient review; inpatient site of service appropriateness; inpatient rehabilitation and skilled nursing facility review; and outpatient-based services or procedures where there is not an established Medical Policy or Clinical UM Guideline.
Operational: Use MCG as the primary reference for clinical review in these areas.
If MCG Care Guidelines do not cover a behavioral health service, the following standardized tools are used for medical necessity determinations: Adults: Level of Care Utilization System (LOCUS); Children and Adolescents: Child and Adolescent Service Intensity Instrument (CASII); Young Children: Early Childhood Service Intensity Instrument (ECSI).
Operational: Apply the appropriate instrument based on member age and service type.
American Society of Addiction Medicine (ASAM) criteria are used for substance use services in accordance with state requirements.
Operational: Apply ASAM when assessing level of care for substance use treatment per state guidance.
Medicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines (when approved by the Department for Medicaid Services) supersede MCG Care Guidelines.
Operational: When conflicts exist, follow the hierarchy: state contract/regulatory/CMS → Anthem Medical Policy/Clinical UM Guidelines (if DMS-approved) → MCG.
Medical necessity determinations are made on a case-by-case basis in accordance with the definition of medical necessity contained within the Medicaid state contract, regulatory guidance, CMS requirements, or Anthem Medical Necessity Criteria Policy ADMIN.OO004.
Operational: Reference ADMIN.OO004 for the plan’s medical necessity definition and apply case-by-case review.
If a request does not meet established criteria or guidelines, it will be referred to a licensed physician reviewer with appropriate clinical expertise to make a decision.
Operational: Requests that fail automated or guideline-based criteria require physician-level review and documentation of the rationale.

Documentation Required

Requests Not Meeting Criteria — Referral and Determination

Requests not meeting established criteria will be referred to a licensed physician reviewer; determinations are case-by-case per Medicaid contract/regulatory/CMS requirements and Anthem Medical Necessity Criteria ADMIN.OO004.

Requests not meeting established criteria will be referred to a licensed physician reviewer with appropriate clinical expertise.
Determinations are made case-by-case in accordance with Medicaid contract/regulatory/CMS requirements and Anthem Medical Necessity Criteria ADMIN.OO004.

Prior Authorization

Pre-payment review when no other UM guideline exists

Pre-payment review (prior authorization) processes apply when no other UM guideline exists. See CG-ADMIN-01 for the Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists.

Reference code: CG-ADMIN-01.
Prior authorization/pre-payment review processes apply for services without an established Clinical UM Guideline.

Enumerated Clinical UM Criteria and identifiers adopted

This listing is an enumerated catalog of the Clinical UM Criteria titles and identifiers adopted by Anthem Blue Cross and Blue Shield Medicaid (Ohio). It presents the adopted criteria as individual entries (CG-, DME-, LAB-, MED-, REHAB-, SURG-, RAD-, ED-, TRANS.-type identifiers and others) and notes that many items in the listing are marked as New or have blank metadata fields.

Listed Criteria Identifiersmixed

CG-ADMIN-01	Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists
CG-ANC-04	Ambulance Services: Air and Water
CG-ANC-05	Ambulance Services: Ground; Emergent
CG-ANC-06	Ambulance Services: Ground; Non-Emergent
CG-ANC-08	Mobile Device-Based Health Management Applications
CG-BEH-15	Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
CG-DME-04	Electrical Nerve Stimulation, Transcutaneous, Percutaneous
CG-DME-06	Pneumatic Compression Devices for Lymphedema
CG-DME-09	Continuous Local Delivery of Analgesia to Operative Sites using an Elastomeric Infusion Pump during the Post-Operative Period
CG-DME-18	Home Oxygen Therapy

1–10 of 75

1/8

The listing also includes numerous Carelon and Carelon MBM entries and a wide range of DME, LAB, ED, RAD, SURG and TRANS items referenced in the criteria catalog. Multiple entries were indicated as New (adopted by the Medical Operations Committee on 2023-09-28); see the changes listing for details.

Term	Definition
MCG Care Guidelines
External clinical guidance used by the plan for medical necessity and site-of-service determinations when internal Medical Policies/UM Guidelines do not apply.
LOCUS/CASII/ECSI
Standardized tools used for behavioral health medical necessity determinations for adults/children/young children respectively.
ASAM
American Society of Addiction Medicine criteria used for substance use services according to state requirements.

Operational impacts and required actions for providers

Documentation Required

Medical necessity determinations and referral to physician reviewer

If a request does not meet established criteria or guidelines it will be referred to a licensed physician reviewer with appropriate clinical expertise. Medical necessity determinations are made on a case-by-case basis in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, or Anthem Medical Necessity Criteria Policy ADMIN.OO004.

Make determinations case-by-case per Medicaid/state contract, regulatory guidance, CMS requirements and Anthem Medical Necessity Criteria ADMIN.OO004.
Refer requests that do not meet established criteria to a licensed physician reviewer with appropriate clinical expertise.

Prior Authorization

Pre-payment review when no other UM guideline exists

CG-ADMIN-01 is the Clinical Utilization Management Guideline for pre-payment review medical necessity determinations when no other Clinical UM Guideline exists and applies to prior authorization/pre-payment review processes for services lacking an established guideline.

Affected code: CG-ADMIN-01
Applies to pre-payment/prior authorization review when no other UM guideline exists.

Policy Summary

PayerAnthem Blue Cross and Blue Shield Medicaid (Ohio)

PolicyClinical Utilization Management Guidelines

Policy CodePolicy N/A

Change TypeList/Adoption of Criteria (many items marked New)

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Clinical Utilization Management Guidelines

Policy summary and high-level details

Use of external and internal guidelines for utilization management

Enumerated Clinical UM Criteria and identifiers adopted

Definitions and reference tools

Operational impacts and required actions for providers

Document changes and adoption notes