Clinical Utilization Management Guidelines (Anthem Wisconsin Medicaid) - CUMG listing for DME and other categories
This document lists the Clinical Utilization Management (CUMG) guidelines Anthem Blue Cross and Blue Shield has adopted for Wisconsin BadgerCare Plus and Medicaid SSI programs and indicates which guidelines are new; it informs providers about the available CUMG topics and their use for medical necessity and utilization review.
No material clinical or coverage changes in this revision.
Coverage Criteria Overview
This document describes how Anthem uses MCG Care Guidelines for Wisconsin BadgerCare Plus and Medicaid SSI programs. The guidelines are applied only for the specific purposes listed by Anthem: medical necessity review for medical and behavioral health inpatient care, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and for outpatient services or procedures when there is no established Anthem Medical Policy or Clinical UM Guideline. Medicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines. Determinations of medical necessity are made on a case‑by‑case basis in accordance with the Medicaid state contract, CMS requirements, and Anthem’s Medical Necessity Criteria Policy; requests that do not meet established criteria are referred to a licensed physician reviewer with appropriate clinical expertise.
What Providers Need to Know
Use of Clinical Utilization Management Guidelines (CUMG) for medical necessity review
Anthem uses MCG (MCG Care Guidelines) for clinical utilization management in specific scenarios. MCG is applied for medical necessity review of inpatient medical and behavioral health requests, determining inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility reviews, and for outpatient services or procedures when no established Anthem Medical Policy or Clinical UM Guideline exists. State Medicaid contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines take precedence over MCG. ASAM criteria are used for substance use services when required by state rules. Medical necessity determinations are made case-by-case according to the applicable Medicaid state contract, regulatory guidance, CMS requirements, or Anthem's Medical Necessity Criteria Policy (ADMIN.OOO04). If a request does not meet the applicable guideline criteria, it will be referred to a licensed physician reviewer with appropriate clinical expertise for a determination.
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