CurrentBlue Cross Blue Shield - MainePolicy N/A

Clinical Utilization Management Guidelines (list of adopted UM criteria)

This document lists Clinical Utilization Management (UM) Guidelines and Medical Policy criteria adopted by the health plan for use in medical necessity and utilization review decisions; it affects providers requesting coverage or prepayment review for services under the plan.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyClinical Utilization Management Guidelines (list of adopted UM criteria)

Policy CodePolicy N/A

Change TypeInformational listing — no material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders must follow the listed Clinical UM Guidelines and Medical Policies when requesting authorization and provide documentation consistent with those guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+criteria and policies listed

MultipleLAB-specific criteria included

Jun 27, 2024adoption date

Adopted Clinical UM Criteria and Coverage Rules

Summary — Refer to specific guideline

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.

Listed Criteria: This document lists multiple Clinical Utilization Management (UM) Guidelines and Medical Policies by code and title. Each referenced guideline (e.g., CG-LAB-03, CG-LAB-10, LAB.00011, LAB.00050, etc.) contains the specific AND/OR criteria that govern medical necessity and coverage determinations.

Providers must consult the referenced guideline for the exact medical necessity criteria and frequency limits.

Coverage determinations follow the plan's hierarchy of authorities. Medicaid state contracts, regulatory guidance, CMS requirements, and approved Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines. When making pre‑payment reviews or medical necessity decisions for services listed in this document, reviewers apply the specific Clinical UM Guideline or Medical Policy referenced by code (for example, CG‑LAB or LAB criteria) to determine whether an individual request meets the established clinical criteria.

If a request does not meet the established criteria in the referenced guideline, the case will be referred to a licensed physician reviewer with appropriate clinical expertise. Such referrals may result in a determination of not medically necessary after clinical review in accordance with the applicable Medicaid contract, regulatory guidance, CMS requirements, or the plan's Medical Necessity Criteria Policy.

Tests and Panels Governed by Specific Guidelines

Covered indications governed by specific Clinical UM Guidelines

Various laboratory tests and panels are governed by specific Clinical UM Guidelines listed below; coverage is determined by each guideline's clinical prerequisites and criteria.

Listed Lab Criteria: The listed CG-LAB and LAB criteria (for example: CG-LAB-03 Tropism Testing for HIV Management; CG-LAB-10 Zika Virus Testing; CG-LAB-14 Respiratory Viral Panel Testing; LAB.00011 Selected Protein Biomarker Algorithmic Assays; LAB.00050 Metagenomic Sequencing for Infectious Disease; LAB.00015 Detection of Circulating Tumor Cells; LAB.00019 Proprietary Algorithms for Liver Fibrosis; LAB.00026 Systems Pathology and Multimodal AI Testing for Cancer) define coverage, clinical indications, and any test-specific prerequisites.

Providers must consult the specific CG-LAB or LAB guideline referenced for the required clinical documentation, ordering requirements, test frequency, and any authorization steps.

Listed Clinical and Laboratory Criteria / Codes

Listed Clinical and Laboratory Criteriamixed

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

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Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior authorization requirement — follow listed Clinical UM Guidelines

Pre-payment review and medical necessity determinations for services referenced in the listed Clinical UM Guidelines and Medical Policies will use the adopted criteria; providers must follow the applicable criteria when requesting authorization for services (for example, CG-LAB-03, CG-LAB-10, LAB.00011, etc.).

Authorization requests for services referenced by a listed guideline must reference and meet that guideline's criteria.

Step Therapy

Use of standardized tools for level-of-care determinations

MCG Care Guidelines and, when applicable, standardized tools (LOCUS, CASII, ECSII, ASAM) may be used to determine level-of-care, inpatient site-of-service, or for outpatient services lacking an established Medical Policy or Clinical UM Guideline.

Use MCG for medical and behavioral health inpatient review and site-of-service decisions.
When MCG does not cover a behavioral health service, use LOCUS, CASII, ECSII, or ASAM as applicable.

Documentation Required

Documentation expectations — use published Medical Policies and Clinical UM Guidelines

Providers should use the publicly available Medical Policies and Clinical UM Guidelines on the insurer's website to support medical necessity determinations and supply documentation consistent with those guidelines.

Include documentation that demonstrates how the requested service meets the specific criteria in the referenced guideline.

Denial Risk

Denial triggers — nonconforming requests may be denied

If a request does not meet the established criteria guidelines it will be referred to a licensed physician reviewer with appropriate clinical expertise and may be denied if medical necessity is not met.

Requests failing to demonstrate adherence to the specific guideline criteria risk denial after physician review.

Ordering and Authorization Expectations

Billing Rule

ORDERING REQUIREMENTS — follow Medical Policies, Clinical UM Guidelines, and applicable MCG guidance

Ordering and authorization must follow the insurer's Medical Policies and Clinical UM Guidelines; where MCG or other standardized tools apply, follow the applicable guidance and processes for authorization and documentation.

When no Medical Policy/Clinical UM Guideline exists for an outpatient service, apply MCG guidance for ordering and level-of-care decisions.
Medicaid state contracts, regulatory guidance, CMS requirements and approved Medical Policy/Clinical UM Guidelines supersede MCG where applicable.

Frequency and Repeat Testing Rules

Frequency limits — summary

Frequency limitsNot specified in this listing document; frequency limits are contained within each specific guideline.

Where to find limitsSee the referenced CG-LAB or LAB guideline for test-specific frequency and interval rules.

ScopeApplies to all laboratory tests listed in this document; individual guidelines govern repeat testing and timing.

DocumentationFrequency determinations are documented within each Clinical UM Guideline or Medical Policy linked to the test code.

Standardized Clinical Guidelines and Tools

Standardized clinical guidelines used for medical necessity review and site-of-service appropriateness

Standardized guidelineMCG Care Guidelines

Primary usesMedical necessity review for medical and behavioral health inpatient review, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review.

Outpatient useUsed for outpatient services or procedures when there is not an established Medical Policy or Clinical UM Guideline.

Supplemental toolsIf MCG does not cover a behavioral health service, LOCUS, CASII, ECSII, and ASAM criteria may be used as applicable.

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

Background and Rationale

The plan uses MCG Care Guidelines for medical necessity review in multiple settings including medical and behavioral health inpatient review, inpatient site‑of‑service appropriateness, inpatient rehabilitation and skilled nursing facility review, and certain outpatient services when no established Medical Policy or Clinical UM Guideline exists. When MCG does not cover a behavioral health service, other standardized tools (LOCUS, CASII, ECSII, ASAM) are used as appropriate.

Tests and Technologies With Limited or No Coverage

This document lists several specialized and proprietary laboratory tests and panels that are addressed by individual Clinical UM Guidelines (LAB.xxx entries). Examples include algorithmic biomarker assays, systems pathology and multimodal artificial intelligence testing, machine learning‑derived probability scores, and metagenomic sequencing. Coverage for these tests is determined by their specific LAB or CG‑LAB guideline and may be limited, investigational, or subject to conditions specified in the referenced guideline.