CurrentAnthemPolicy N/A

Clinical Utilization Management Guidelines (Anthem Ohio Medicaid)

Lists the Clinical Utilization Management (UM) Guidelines and criteria adopted by Anthem Blue Cross and Blue Shield Medicaid for Ohio Medicaid Managed Care, describing their use for medical necessity and utilization review across services and settings and who must follow them (providers treating Anthem Ohio Medicaid members).

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines (Anthem Ohio Medicaid)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionUse the listed Clinical UM Criteria and applicable state/CMS requirements to determine coverage and consult the linked criteria when prior authorization is needed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+distinct criteria/guideline items listed

MCGMCG Care Guidelines referenced

Jun 22, 2023adoption date

OhioMedicaid state

Application of Clinical Utilization Management Criteria

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines (Anthem Ohio Medicaid)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionUse the listed Clinical UM Criteria and applicable state/CMS requirements to determine coverage and consult the linked criteria when prior authorization is needed.

SourceLink

On This Page

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Governance and application: Medical necessity and prior authorization determinations must follow (1) the listed Anthem Medical Policies/Clinical UM Guidelines for the specific service, (2) Medicaid state contract/regulatory guidance and CMS requirements, and (3) when applicable, MCG Care Guidelines; behavioral health level-of-care uses LOCUS (adults), CASII (children/adolescents), ECSI (young children) and ASAM criteria for substance use services per state requirements.

To view individual criteria, follow the links to each Clinical UM Guideline on the Anthem provider site; the criteria list was adopted by the Medical Operations Committee on June 22, 2023.

Coverage determinations for Anthem Ohio Medicaid follow the hierarchy of authoritative sources: Medicaid state contracts, state regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines as approved by the Department for Medicaid Services (DMS). When a specific Anthem Medical Policy or Clinical UM Guideline for a service is not available, the plan may apply the MCG Care Guidelines for medical necessity and site-of-service decisions.

Listed Clinical UM Criteria Codes

Listed Clinical UM Criteria codes (sample group)mixed

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-DME-04	Electrical Nerve Stimulation, Transcutaneous, Percutaneous
CG-DME-06	Pneumatic Compression Devices for Lymphedema
CG-DME-18	Home Oxygen Therapy
CG-DME-22	Ankle-Foot & Knee-Ankle-Foot Orthoses
CG-GENE-04	Molecular Marker Evaluation of Thyroid Nodules
CG-LAB-03	Tropism Testing for HIV Management

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Provider Requirements and Denial Risk

Denial Risk

Denial risk when criteria not met

Requests that do not meet the listed clinical criteria will be referred to a licensed physician reviewer with appropriate clinical expertise. A determination that the request does not meet medical necessity criteria may result in denial of payment or prior authorization. Providers should ensure documentation clearly demonstrates how the request meets all applicable Clinical UM Criteria and Medical Policy requirements to avoid delays or denials.

Requests not meeting criteria will be escalated to a licensed physician reviewer.
Denials may be issued when medical necessity criteria are not met.

Documentation Required

Documentation and authoritative sources

Providers must use and reference publicly available Anthem Medical Policies and Clinical UM Guidelines when submitting requests for services. Medicaid state contracts, regulatory guidance, CMS requirements, and approved Medical Policy/Clinical UM Guidelines supersede other guidance. Maintain complete clinical records and include any supporting documentation cited by Anthem policies or Clinical UM Criteria at the time of submission.

Refer to the Anthem Medical Policy and Clinical UM Guideline subsidiary website for the full list of policies and guidelines.
Medicaid state contracts and CMS requirements take precedence when applicable.

Prior Authorization

Behavioral health level-of-care tools

When MCG Care Guidelines do not address a behavioral health service, Anthem uses standardized level-of-care tools for medical necessity determinations: LOCUS for adults, CASII for children and adolescents, and ECSI for young children. ASAM criteria are used for substance use services per state requirements. Use these tools and document results when requesting behavioral health inpatient or other behavioral health services.

Adults: Level of Care Utilization System (LOCUS).
Children & Adolescents: Child and Adolescent Service Intensity Instrument (CASII).
Young Children: Early Childhood Service Intensity Instrument (ECSI).
Substance use services: American Society of Addiction Medicine (ASAM) criteria as required by state regulations.

Background and Guideline Use

The plan uses MCG Care Guidelines for medical necessity review across settings including inpatient medical and behavioral health reviews, assessment of inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services or procedures when no Anthem Medical Policy or Clinical UM Guideline exists. For behavioral health services not covered by MCG, validated level-of-care instruments are used: LOCUS for adults, CASII for children and adolescents, and ECSI for young children; ASAM criteria are applied for substance use services per state requirements.

Defined Tools and Guidelines

MCG Care Guidelines — standardized care guidelines used when no other Anthem Medical Policy exists

DefinitionMCG Care Guidelines are a standardized set of care guidelines used by the plan for medical necessity and site-of-service determinations when no other Anthem Medical Policy or Clinical UM Guideline applies.

When usedFor medical necessity review of medical and behavioral health inpatient care, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and for outpatient services/procedures when no established Anthem Medical Policy or Clinical UM Guideline exists.

LimitationsMedicaid 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.

Decision processMCG may be used as the default clinical guideline, but determinations of medical necessity are made case-by-case per the Medicaid state contract, regulatory guidance, CMS requirements, or Anthem's Medical Necessity Criteria Policy.

Action when criteria not metIf a request does not meet established criteria/guidelines, it will be referred to a licensed physician reviewer with appropriate clinical expertise for a determination.

LOCUS / CASII / ECSI — standardized behavioral health level-of-care tools for adults, children/adolescents, and young children

LOCUSLevel of Care Utilization System — standardized tool used for adult behavioral health level-of-care determinations.

CASIIChild and Adolescent Service Intensity Instrument — standardized tool used for children and adolescent behavioral health level-of-care determinations.

ECSIEarly Childhood Service Intensity Instrument — standardized tool used for behavioral health level-of-care determinations for young children.

Substance useAmerican Society of Addiction Medicine (ASAM) criteria are used for substance use services according to state requirements.