Clinical Utilization Management Guidelines (Directory of Clinical UM Criteria)
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A listing of Anthem/Anthem Blue Cross and Blue Shield Medicaid Clinical Utilization Management (UM) Guidelines and MCG usage notes that govern prior authorization and medical necessity review processes for covered services and providers.
No material clinical or coverage changes in this revision.
Clinical Utilization Management Criteria
Directory of Clinical UM Criteria (links to individual guideline decision logic)
Covered when ALL of the following are met: this document serves as a directory linking each listed Clinical UM Criteria identifier to the full guideline containing the specific medical necessity decision logic.
This document catalogs available Clinical UM Guidelines and does not itself contain the full decision logic; providers must refer to the linked guideline for complete criteria.
MCG Care Guidelines are the externally developed clinical guidelines used by the plan for medical necessity review for inpatient services, site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and for certain outpatient services where no Anthem Medical Policy or Clinical UM Guideline exists. Medicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines approved by the Department for Medicaid Services (DMS) supersede MCG Care Guidelines when applicable.
Requests that do not meet the established Clinical UM Criteria or MCG guideline criteria will be referred to a licensed physician reviewer with appropriate clinical expertise. Following that physician review, the request may be determined not medically necessary if it does not satisfy the applicable criteria or the definition of medical necessity contained in the Medicaid state contract, regulatory guidance, CMS requirements, or Anthem Medical Necessity Criteria Policy.
Listed Clinical UM Criteria Identifiers
| 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-02 | Adaptive Behavioral Treatment. |
| CG-BEH-15 | Activity Therapy for Autism Spectrum Disorders and Rett Syndrome. |
| 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. |
What Providers Must Do / Follow-Up Actions
Use of MCG and behavioral health level-of-care tools
MCG Care Guidelines are 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 for outpatient services/procedures when there is not an established Medical Policy or Clinical UM Guideline. When MCG does not cover a behavioral health service, the plan uses standardized level-of-care tools: Adults — LOCUS; Children and Adolescents — CASII; Young Children — ECSII. ASAM criteria are used for substance use services as required by state rules. Medicaid state contracts, regulatory guidance, CMS requirements, and our Medical Policy/Clinical UM Guidelines (when approved by the Department for Medicaid Services) supersede MCG.
- Adults: Level of Care Utilization System (LOCUS)
- Children & Adolescents: Child and Adolescent Service Intensity Instrument (CASII)
- Young Children: Early Childhood Service Intensity Instrument (ECSII)
- Substance use services: American Society of Addiction Medicine (ASAM) criteria
CG-ADMIN-01 — fallback guideline
When no other Clinical UM Guideline exists, CG-ADMIN-01 (Clinical Utilization Management Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists) is applied as the fallback guideline for prior authorization and medical necessity review. Determinations of medical necessity are made case-by-case in accordance with the applicable Medicaid state contract, regulatory guidance, CMS requirements, and our Medical Necessity Criteria Policy (ADMIN.OO004).
- Fallback guideline: CG-ADMIN-01 (Pre-Payment Review when no other Clinical UM Guideline exists)
- Medical necessity definition: per Medicaid state contract/regulatory guidance/CMS requirements or ADMIN.OO004
Nonconcordant requests and referral to physician reviewer
If a requested service does not meet the applicable guideline criteria, the request will be referred to a licensed physician reviewer with the appropriate clinical expertise for a determination. Nonconcordant requests that do not meet criteria may be denied.
- Requests not meeting guideline criteria are reviewed by a licensed physician reviewer
- Nonconcordant requests may be denied
Where to find full criteria and basis for determinations
The full list of Medical Policies and Clinical UM Guidelines and the basis for our determinations are publicly available on the Medical Policy and Clinical UM Guideline website. Providers should consult the complete guideline text for criteria, rationale, and any state-specific exceptions.
- Access full criteria and determination rationale at the Medical Policy and Clinical UM Guideline subsidiary website
- For additional information and links to specific criteria see the Clinical Utilization Management Criteria listing (e.g., CG-ADMIN-01)
Background
This document functions as a directory of Anthem Clinical Utilization Management (UM) Criteria: each listed CG- or CG-
Definitions and Tools
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