CurrentAnthemPolicy N/A

Clinical Utilization Management Guidelines (Anthem Ohio Medicaid) - Index of Clinical UM Criteria

List and indexing of Clinical Utilization Management (UM) Guidelines and Medical Policies adopted by Anthem Blue Cross and Blue Shield Medicaid for Ohio Medicaid Managed Care; informs providers what guidelines are used for medical necessity and utilization review processes.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines — index of Clinical UM Criteria for Ohio Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse the listed Clinical UM Criteria and MCG Care Guidelines for medical necessity and prior authorization review and reference full Medical Policies on the Anthem subsidiary website when submitting requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~120+listed Clinical UM Criteria items and Medical/ Lab policies referenced

Jun 27, 2024committee adoption date

Ohio Medicaidapplicable program

Publicpolicies location

Clinical Utilization Management Criteria Index

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines — index of Clinical UM Criteria for Ohio Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Index of Clinical UM Criteria (see linked criteria for full coverage rules)

The listed Clinical UM Criteria were adopted and apply for medical necessity and utilization review for Anthem Ohio Medicaid members (see individual criteria for full coverage rules).

ALL of the following

Index of Clinical UM Criteria (see linked criteria for full coverage rules).
Adopted criteria list includes clinical, laboratory, device, surgical and other specialty guideline titles used for pre-payment and medical necessity determinations; consult each referenced criterion for specific coverage rules and frequency limits.

When applying the Clinical UM Criteria listed in this index, Medicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines take precedence and supersede MCG Care Guidelines where applicable. MCG Care Guidelines are used for medical necessity review for inpatient services, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and for outpatient services when no specific Medical Policy or Clinical UM Guideline exists. Determinations of medical necessity are made on a case-by-case basis in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, or Anthem’s Medical Necessity Criteria Policy.

This index does not list every circumstance that would be considered not medically necessary. Specific determinations about services that are not medically necessary will be made according to the referenced Clinical UM Criteria, Medical Policies, applicable Medicaid contract language, and regulatory/CMS requirements. Requests that do not meet the established criteria will be referred to a licensed physician reviewer and may be denied.

Laboratory-Related Clinical UM Criteria and Policies

Laboratory-related Clinical UM Criteria (selected titles)

This listing includes the laboratory-related Clinical UM Criteria titles referenced in the index; consult each listed LAB.* policy or Clinical UM Guideline for the specific covered indications and medical necessity criteria.

ALL of the following

Laboratory-related criteria included (examples)
- CG-LAB-03: Tropism Testing for HIV Management.
- CG-LAB-10: Zika Virus Testing.
- CG-LAB-11: Screening for Vitamin D Deficiency in Average Risk Individuals.
- CG-LAB-14: Respiratory Viral Panel Testing in the Outpatient Setting.
- CG-LAB-16: Serum Amylase Testing.
- CG-LAB-17: Molecular Gastrointestinal Pathogen Panel (GIPP) Testing for Infectious Diarrhea in the Outpatient Setting.
- CG-LAB-20: Thyroid Testing.
- CG-LAB-21: Serum Iron Testing.
- CG-LAB-24: Outpatient Urine Culture.
- CG-LAB-25: Outpatient Glycated Hemoglobin and Protein Testing.
- CG-LAB-26: Outpatient Alpha-Fetoprotein Testing.
- CG-LAB-27: Human Chorionic Gonadotropin Testing.
- CG-LAB-28: Prostate Specific Antigen (PSA) Testing.
- CG-LAB-29: Gamma Glutamyl Transferase (GGT) Testing.
- CG-LAB-30: Outpatient Laboratory-based Blood Glucose Testing.
- LAB.00011: Selected Protein Biomarker Algorithmic Assays.
- LAB.00015: Detection of Circulating Tumor Cells.
- LAB.00019: Proprietary Algorithms for Liver Fibrosis.
- LAB.00024: Immune Cell Function Assay (listed in index).
- LAB.00050: Metagenomic Sequencing for Infectious Disease in the Outpatient Setting (listed in index).

Provider Responsibilities and Authorization

Prior Authorization

Prior Authorization and Clinical Criteria

Use of listed Clinical UM Criteria for prior authorization — MCG and referenced criteria govern medical necessity and pre-payment review. The full list of Medical Policies and Clinical UM Guidelines are publicly available on the Medical Policy and Clinical UM Guideline subsidiary website. Providers should reference these full Medical Policies and Clinical UM Guidelines when submitting authorization requests or supporting documentation.

MCG Care Guidelines are used for medical necessity review for inpatient care, inpatient site-of-service appropriateness, inpatient rehabilitation and SNF review, and outpatient services where no Medical Policy/Clinical UM Guideline exists.
If MCG does not cover a behavioral health service, LOCUS, CASII, ECSI, or ASAM criteria (for substance use) are used where applicable.
Medicaid state contracts, regulatory guidance, CMS requirements and approved Medical Policy/Clinical UM Guidelines supersede MCG when applicable.

Step Therapy

Step therapy not specifically detailed in the listed criteria. Where step therapy requirements would apply, reviewers will follow the applicable Medical Policy, Clinical UM Guideline, or MCG guidance used for the level-of-care or service type. Providers should include prior treatment history and rationale when submitting requests if step therapy might be relevant.

Note

Reference and Communications

Reference and communications — Providers must reference the full Medical Policies and Clinical UM Guidelines on the Anthem subsidiary website when submitting requests or supporting documentation. Communications about prior authorization determinations may include referral to the Medical Policy/Clinical UM Guidelines and applicable state or CMS requirements.

When submitting requests, include links or citations to the specific Medical Policy/Clinical UM Guideline or MCG criteria relied upon, when known.
If a guideline is not available for a requested service, note the use of MCG or other standardized tools in the request.

Denial Risk

Failure to Meet Criteria / Denial Risk

Failure to meet criteria may trigger denial — Requests that do not meet established Medical Policy, Clinical UM Guideline, or MCG criteria will be referred to a licensed physician reviewer with appropriate clinical expertise and may be denied.

Denial risk applies when submitted documentation is insufficient to demonstrate medical necessity per the referenced criteria.
Providers have the opportunity to provide additional clinical information or appeal determinations in accordance with plan processes.

Frequency and Repeat Testing

Frequency limits

Frequency limitsNot specified in this index; frequency limits are defined in the individual Clinical UM Guidelines (see each CG-LAB or LAB.* policy).

Where to find limitsRefer to the specific Clinical UM Guideline or Medical Policy (e.g., CG-LAB-03, CG-LAB-11, LAB.00011) for test‑specific frequency rules.

ScopeApplies to the laboratory-related criteria listed in this index (e.g., Tropism Testing, Respiratory Viral Panel, GIPP, Thyroid Testing).

Action for providersUse the linked individual guideline or LAB.* policy for allowable testing intervals when ordering or requesting authorization.

Key Definitions

MCG Care Guidelines

DefinitionMCG Care Guidelines are commercial clinical guidelines used by Anthem for medical necessity review, inpatient site‑of‑service appropriateness, inpatient rehabilitation and SNF review, and outpatient services or procedures where there is not an established Medical Policy or Clinical UM Guideline.

Behavioral health exceptionsIf MCG Care Guidelines do not cover a behavioral health service, standardized tools (LOCUS, CASII, ECSI) and ASAM criteria are used per state requirements.

Superseding guidanceMedicaid state contracts, regulatory guidance, CMS requirements, and approved Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines when applicable.

Medical necessity determination

DefinitionMedical necessity determinations are made on a case‑by‑case basis in accordance with the definition of medical necessity contained in the Medicaid state contract, regulatory guidance, CMS requirements, or Anthem's Medical Necessity Criteria Policy (ADMIN.00004).

Reviewer processIf a request does not meet established criteria guidelines, it will be referred to a licensed physician reviewer with appropriate clinical expertise to make a decision.

Interaction with guidelinesDecisions follow referenced Clinical UM Guidelines, Medical Policies, Medicaid contract and regulatory requirements; those authorities supersede other guidance when applicable.

OpenPayer

Clinical Utilization Management Guidelines (Anthem Ohio Medicaid) - Index of Clinical UM Criteria

Clinical Utilization Management Criteria Index

Laboratory-Related Clinical UM Criteria and Policies

Coding Information

Provider Responsibilities and Authorization

Ordering and Prior Authorization

Frequency and Repeat Testing

Key Definitions

Policy Background

Exclusions and Not Covered Services