CurrentAnthemPolicy N/A

November 2023 Clinical Utilization Management Guidelines

Lists Clinical Utilization Management Guidelines adopted for Anthem HealthKeepers Plus Medicaid members, indicating which CUMG/CG items are new as of Medical Operations Committee adoption on December 21, 2023; provides purpose and use of MCG Care Guidelines and related administrative notes.

Policy Summary

PayerAnthem

PolicyNovember 2023 Clinical Utilization Management Guidelines

Policy CodePolicy N/A

Change TypeAdded guidelines (new items)

Effective DateDec 21, 2023

Next Review DateN/A

Key ActionProviders should view individual guidelines on the Coverage Guidelines and Clinical UM Guideline subsidiary website or Provider Medical Policy Search Results to determine specific medical necessity criteria and prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

Multiple Clinical Utilization Management Guidelines were indicated as new and adopted by the Medical Operations Committee for Anthem HealthKeepers Plus members on December 21, 2023.

150+Guidelines listed

2023-12-21Adoption date

Anthem HealthKeepers Plus MedicaidPlan scope

What changed — snapshot

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This bulletin communicates the list of Clinical Utilization Management Guidelines adopted for Anthem HealthKeepers Plus Medicaid members and notes which CUMG/CG items were indicated as new at the Medical Operations Committee meeting on 2023-12-21.

It explains the role of MCG Care Guidelines and the ASAM criteria in certain reviews and directs providers to the public Coverage Guidelines site for full guideline content. It also states that Medicaid state contracts, regulatory guidance and CMS requirements supersede MCG guidance.

Listed Clinical Utilization Management Guidelines

Listed Clinical Utilization Management Guidelines (by identifier and title)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-03	Acupuncture
CG-ANC-04	Ambulance Services: Air and Water
CG-ANC-05	Ambulance Services: Ground; Emergent
CG-ANC-06	Ambulance Services: Ground; Nonemergent
CG-ANC-07	Inpatient Interfacility Transfers
CG-ANC-08	Mobile Device-Based Health Management Applications
CG-BEH-14	Intensive In-Home Behavioral Health Services
CG-BEH-15	Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
CG-DME-03	Neuromuscular Stimulation in the Treatment of Muscle Atrophy

1–10 of 212

1/22

What providers need to do

Note

Access to full guidelines

Providers should view individual guidelines on the Coverage Guidelines and Clinical UM Guideline subsidiary website or Provider Medical Policy Search Results to determine specific medical necessity criteria and prior authorization requirements.

Documentation Required

Medical necessity determinations and referral to physician reviewer

If a request does not meet established criteria guidelines, the case will be referred to a licensed physician reviewer with appropriate clinical expertise for decision-making.

Documentation Required

MCG Care Guidelines limited use

MCG Care Guidelines are used only for specified inpatient and outpatient scenarios (medical and behavioral health inpatient review; inpatient site-of-service appropriateness; inpatient rehabilitation and skilled nursing facility review; and outpatient services or procedures when no other Coverage or Clinical UM Guideline exists) and are superseded by Medicaid state contracts, regulatory guidance, CMS requirements and Anthem Coverage/Clinical UM Guidelines.

Prior Authorization

Questions and contact

For questions or case-specific inquiries, providers should call Provider Services or sign up for email communications via the provided link/QR code.

Provider Services: 800-901-0020
Sign up for email communications via link/QR code

Definitions and use of referenced criteria

MCG Care Guidelines: Proprietary clinical guidelines used for specified reviews — including medical and behavioral health inpatient medical necessity review, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and for outpatient services or procedures when no other Coverage or Clinical UM Guideline exists.

ASAM criteria: The American Society of Addiction Medicine criteria used for substance abuse services as required by state guidance; applied according to state requirements for those services.