CurrentBlue Cross Blue Shield - MainePolicy N/A

Clinical Utilization Management Guidelines (Clinical UM Criteria catalog)

A catalog of Clinical Utilization Management (UM) Criteria and Medical Policies adopted by Anthem Blue Cross and Blue Shield Medicaid (Ohio Medicaid Managed Care) describing guidelines used for medical necessity determinations and related resources; intended for providers and plan administrators.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyClinical Utilization Management Guidelines (Clinical UM Criteria catalog)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionUse the listed Clinical UM Criteria for prior authorization and pre-payment review when no other guideline exists.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+listed Clinical UM Criteria and Medical Policy items

Dec 21, 2023adoption date for new criteria

MCGExternal guideline source referenced for inpatient reviews

Adopted Clinical UM Criteria

Adopted Clinical UM Criteria (catalog)

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Medicaid state contracts, regulatory guidance, CMS requirements and approved Medical Policy/Clinical UM Guidelines take precedence over other guidance when the Department for Medicaid Services has approved them. For medical necessity determinations, 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 for outpatient services or procedures when there is no established Medical Policy or Clinical UM Guideline. Providers should follow the applicable Medicaid contract and regulatory requirements, and consult the Medical Policy or Clinical UM Guideline approved by the Department where available.

Listed Clinical UM Criteria Identifiers

Listed Clinical UM Criteria 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	cundname PY for Autism Spectrum Disorders and Rett
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 Operational Guidance

Prior Authorization

Pre-payment review and prior authorization guidance

Requests for services may be subject to pre-payment review and prior authorization. Many of the Clinical UM Criteria listed in our guidelines govern pre-payment review and medical necessity determinations; providers should use the listed criteria when submitting requests. The full list of Medical Policies and Clinical UM Guidelines are publicly available on the Anthem provider site and should be referenced for requirements and documentation standards.

Use the published Medical Policies and Clinical UM Guidelines on the Anthem provider site as the authoritative references for pre-payment review and prior authorization.
MCG Care Guidelines may be used when there is not an established Medical Policy or Clinical UM Guideline; where applicable, use LOCUS, CASII, ECSII or ASAM criteria per state requirements.
Include all required clinical documentation and rationale with your submission to support medical necessity determinations.

Denial Risk

Failure to meet criteria may trigger denial

If a request does not meet the established criteria, it will be referred to a licensed physician reviewer with appropriate clinical expertise. Failure to meet criteria may result in denial or a request for additional documentation; providers should be prepared to supply further clinical information to support the request.

Requests that do not meet the listed Clinical UM Criteria will be escalated to a licensed physician reviewer.
Denials may be issued when documentation does not demonstrate that the request meets medical necessity criteria.
Providers may be asked to submit additional information; timely responses can prevent denial or support reconsideration.

Documentation Required

Reference and documentation sources

Providers should reference the publicly available Medical Policies and Clinical UM Guidelines on the Anthem provider site and follow Medicaid documentation requirements. These resources and state regulatory guidance supersede MCG when applicable. Determinations of medical necessity are made case-by-case in accordance with Medicaid state contract, CMS requirements, and our Medical Necessity Criteria Policy.

Consult the Anthem provider Medical Policy Search Results for current policies and Clinical UM Guidelines.
When Medical Policies/Clinical UM Guidelines have been approved by the Department for Medicaid Services (DMS), they supersede MCG Care Guidelines.
Adhere to Medicaid state contract and CMS requirements when preparing documentation for prior authorization and medical necessity review.

Background and Purpose

This document lists the Clinical Utilization Management (UM) Criteria adopted for Medicaid members to guide medical necessity reviews across inpatient, outpatient, rehabilitation and behavioral health settings. The cataloged criteria were adopted by the Medical Operations Committee and are intended to be used by clinical reviewers and providers when making pre‑payment and prior authorization determinations. When MCG Care Guidelines do not address a behavioral health service, standardized assessment tools — LOCUS for adults, CASII for children and adolescents, ECSII for young children — and ASAM criteria for substance use services are referenced. Requests that do not meet the established criteria will be referred to a licensed physician reviewer for final determination.

Referenced External Guidance and Assessment Tools

MCG Care Guidelines — definition and use case (inv-08)

DefinitionExternal evidence-based guidance used for medical necessity review for 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 established Medical Policy or Clinical UM Guideline exists.

When usedApplied for inpatient reviews (medical and behavioral health), inpatient rehabilitation and skilled nursing facility review, and outpatient services lacking a specific Medical Policy or Clinical UM Guideline.

LimitationsMedicaid state contracts, regulatory guidance, CMS requirements and approved Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.

Decision processDeterminations of medical necessity are made case-by-case per the Medicaid state contract, regulatory guidance, CMS requirements, or Medical Necessity Criteria Policy (ADMIN.OO004).

LOCUS/CASII/ECSII/ASAM — assessment tools (inv-09)

Tools referencedLOCUS (adults); CASII (children and adolescents); ECSII (young children); ASAM criteria (substance use services).

PurposeStandardized assessment tools used when MCG Care Guidelines do not cover a behavioral health service to determine medical necessity.

ASAM noteASAM criteria are used for substance use services according to state requirements.

Application contextThese tools guide medical necessity determinations for behavioral health and substance use services in lieu of MCG coverage for the specific service.