CurrentAnthemPolicy N/A

Clinical Utilization Management Guidelines (Medicaid - Ohio)

List and adoption notice of Anthem Blue Cross and Blue Shield Medicaid Clinical Utilization Management (UM) Guidelines and Medical Policies used for medical necessity determinations and utilization management for Ohio Medicaid members.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines (Medicaid - Ohio)

Policy CodePolicy N/A

Change TypeInformational — adoption/listing of UM guidelines

Effective DateN/A

Next Review DateN/A

Key ActionUse the listed Anthem Clinical UM Criteria and MCG Care Guidelines for medical necessity reviews and site-of-service determinations; refer requests that do not meet criteria to a licensed physician reviewer.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+Clinical UM Criteria and Medical Policy items listed

2023-12-21Adoption date for items indicated as new

Ohio MedicaidMedicaid program governed

Clinical Utilization Management Criteria

General Utilization Management Criteria and Process

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General medical necessity process: Medical necessity determinations are performed using Anthem Medical Policies and Clinical UM Guidelines, and MCG Care Guidelines when no Anthem guideline exists; Medicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines approved by the Department for Medicaid Services (DMS) supersede MCG Care Guidelines.

We make determinations on a case-by-case basis per the Medicaid state contract or Medical Necessity Criteria Policy ADMIN.OO004. If a request does not meet established criteria, it will be referred to a licensed physician reviewer with appropriate clinical expertise.

Use of MCG and behavioral health tools: MCG Care Guidelines are used for inpatient medical and behavioral health reviews, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services/procedures when no established Anthem Medical Policy or Clinical UM Guideline exists.

When MCG does not cover a behavioral health service, standardized tools are used: LOCUS for adults; CASII for children/adolescents; ECSI for young children. ASAM criteria are used for substance use services according to state requirements.

Pre-payment review and when MCG applies: MCG Care Guidelines and Anthem Clinical UM Criteria are used for medical necessity reviews and inpatient/outpatient site-of-service determinations; when no other Clinical UM Guideline exists, a pre-payment review guideline (CG-ADMIN-01) applies.

The Clinical Utilization Management Criteria indicated as new were adopted December 21, 2023; providers may view criteria via the Anthem Provider Medical Policy search.

Anthem uses listed Clinical UM Criteria and MCG Care Guidelines to determine medical necessity for medical and behavioral health inpatient reviews, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services or procedures when there is no established Anthem Medical Policy or Clinical UM Guideline. When MCG Guidance does not address a behavioral health service, Anthem uses standardized tools — LOCUS for adults, CASII for children and adolescents, ECSI for young children — and applies ASAM criteria for substance use services per state requirements. Medicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines approved by the Department for Medicaid Services (DMS) supersede MCG Care Guidelines.

If a requested service or procedure does not meet the established Clinical UM Criteria or MCG Care Guidelines, the request will be referred to a licensed physician reviewer with appropriate clinical expertise. Coverage may be denied following that review in accordance with the definition of medical necessity contained in the applicable Medicaid state contract, regulatory guidance, CMS requirements, or Anthem’s Medical Necessity Criteria Policy ADMIN.OO004.

Listed Clinical UM Criteria and Policy Identifiers (Codes)

Listed Clinical UM Criteria and Medical Policy 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	Autism Spectrum Disorders and Rett (behavioral health related)
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

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Provider Requirements and Impact

Note

Pre-payment review and use of MCG/Anthem criteria

MCG Care Guidelines and Anthem Clinical UM Criteria are used for medical necessity reviews, inpatient/outpatient site-of-service determinations, and other utilization management decisions. Providers should reference the Medical Policy and Clinical UM Guideline subsidiary website for the full list of adopted guidelines and the detailed criteria used for reviews.

Full list of Medical Policies and Clinical UM Guidelines available on the Medical Policy and Clinical UM Guideline subsidiary website
MCG used for inpatient medical/behavioral health review, inpatient site-of-service appropriateness, inpatient rehab and SNF review, and outpatient services lacking an established policy

Denial Risk

Denial risk when criteria not met

If a request does not meet the established MCG or Anthem Clinical UM criteria, the case will be referred to a licensed physician reviewer with appropriate clinical expertise for further review. Requests that remain unsupported by the applicable criteria or clinical oversight may be denied. Providers should ensure documentation clearly supports medical necessity to reduce denial risk.

Denial risk when criteria not met — insufficient documentation or failure to meet criteria may result in denial
Cases not covered by MCG are assessed using LOCUS/CASII/ECSII or ASAM for behavioral health/substance use as applicable

Note

Reference and communications

Providers should consult the Medical Policy and Clinical UM Guideline subsidiary website for full guideline details and links to criteria. Sign up for email notifications on the subsidiary site to receive updates when policies or criteria change. Contact information and submission instructions for prior authorization requests are available on the provider portal.

Reference and communications — visit the Medical Policy and Clinical UM Guideline subsidiary website for full guidelines and sign up for email updates
Contact the provider portal for prior authorization submission instructions and questions

Note

Unspecified provider-action item

Not specified in this document.

Background and Scope

Anthem applies MCG Care Guidelines alongside its own Clinical UM Criteria and Medical Policies to make medical necessity determinations across settings — inpatient, inpatient rehabilitation/skilled nursing, and outpatient — when no Anthem guideline exists. Behavioral health determinations rely on standardized instruments (LOCUS, CASII, ECSI) and ASAM criteria for substance use as required by state rules. All determinations are made case-by-case using the medical necessity definition specified by the Medicaid state contract, regulatory guidance, CMS, or Anthem policy.

Key Definitions and Tools

MCG Care Guidelines

DefinitionExternal clinical guidelines used by Anthem for medical necessity review (medical and behavioral health inpatient), inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services when no Anthem Medical Policy or Clinical UM Guideline exists.

When usedApplied for medical necessity determinations for inpatient care, inpatient rehab/skilled nursing, and outpatient services lacking an established Anthem guideline.

Superseded byMedicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines approved by the Department for Medicaid Services (DMS).

Behavioral health fallback toolsIf MCG does not cover a behavioral health service, standardized tools (LOCUS, CASII, ECSI) and ASAM criteria for substance use are used per state requirements.

Decision processRequests not meeting established criteria are referred to a licensed physician reviewer with appropriate clinical expertise for case-by-case medical necessity determinations.

LOCUS / CASII / ECSI

LOCUSLevel of Care Utilization System — standardized tool for behavioral health medical necessity determinations in adults.

CASIIChild and Adolescent Service Intensity Instrument — standardized tool for behavioral health medical necessity determinations in children and adolescents.

ECSIEarly Childhood Service Intensity Instrument — standardized tool for medical necessity determinations in young children.

ASAM criteriaAmerican Society of Addiction Medicine criteria — used for substance use services according to state requirements.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines (Medicaid - Ohio)

Policy CodePolicy N/A

Change TypeInformational — adoption/listing of UM guidelines

Effective DateN/A

Next Review DateN/A

SourceLink

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