Currentcare_continuumPolicy N/A

Clinical Criteria for Utilization Decisions Desk Procedure

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Defines how Care Continuum (NHP/NHIC/NHAS/NH TPA) applies nationally recognized and regionally developed medical policies and criteria for utilization management reviews affecting reviewers, delegated UM entities, providers, and members for commercial, marketplace, and Medicare Advantage requests.

Policy Summary

Payercare_continuum

PolicyClinical Criteria for Utilization Decisions Desk Procedure

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewMar 27, 2026

Next Review DateMar 1, 2027

Key ActionSubmit prior authorization or advance coverage determination requests with adequate clinical documentation for review against applicable criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

annualreview frequency for UM criteria and medical policies

nationalapplies CMS NCD/LCD and nationally recognized criteria

delegatedUM delegated entities' criteria are followed when applicable

publiccriteria available to providers and members at no cost

Policy Summary

Payercare_continuum

PolicyClinical Criteria for Utilization Decisions Desk Procedure

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewMar 27, 2026

Next Review DateMar 1, 2027

Key ActionSubmit prior authorization or advance coverage determination requests with adequate clinical documentation for review against applicable criteria.

SourceLink

On This Page

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Currentcare_continuumPolicy N/A

Clinical Criteria for Utilization Decisions Desk Procedure

Customize your policy alerts

Sign up for all care_continuum policy alerts

Know when care_continuum releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

Payercare_continuum

PolicyClinical Criteria for Utilization Decisions Desk Procedure

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewMar 27, 2026

Next Review DateMar 1, 2027

Key ActionSubmit prior authorization or advance coverage determination requests with adequate clinical documentation for review against applicable criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

annualreview frequency for UM criteria and medical policies

nationalapplies CMS NCD/LCD and nationally recognized criteria

delegatedUM delegated entities' criteria are followed when applicable

publiccriteria available to providers and members at no cost

Policy Summary

Payercare_continuum

PolicyClinical Criteria for Utilization Decisions Desk Procedure

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewMar 27, 2026

Next Review DateMar 1, 2027

Key ActionSubmit prior authorization or advance coverage determination requests with adequate clinical documentation for review against applicable criteria.

SourceLink

On This Page

Coverage & Criteria Application

Commercial Membership

Order of criteria applied for review varies by membership type:

Commercial Membership Review Sequence: Review request against NHP/NHIC/NHAS internally developed medical policies, MCG, and UM delegated medical policies if applicable; if not available then nationally published criteria; if not available then CMS criteria; if not available then technology assessments and other medical information and published evidence provided by the practitioner requesting service.

applies to commercial membership

Medicare Advantage

Medicare Advantage Review Sequence: Review request against CMS NCD and LCD criteria first, then NHP/NHIC/NHAS internally developed medical policies, MCG, and UM delegated entity policies if applicable, then commercially published criteria. If specific criteria are not available for the requested service, review the request based on the experimental process and the MA member's benefit limitations and provide an objective, evidence-based rationale for the determination. Approve medical service when criteria are met and enter authorization or delegate authorization entry to CM Specialist; requests not meeting CMS, commercial, and regionally developed medical criteria are referred to the Medical Director for denial determination or approval with exception.

approvals must align with Original Medicare benefit limitations unless expanded in the MA Evidence of Coverage

All Medicare Advantage utilization determinations are made within the benefit limitations of Original Medicare unless the MA member's applicable Evidence of Coverage (EOC) explicitly expands coverage. This constraint informs authorization decisions and any deviation from Original Medicare benefits must be supported by provisions in the member's EOC.

When a prior authorization or advance coverage determination request does not meet applicable CMS, commercial, or regionally developed medical criteria, the case is referred to the Medical Director for a determination. The Medical Director will either deny the request or approve it with an exception, documenting the rationale consistent with clinical evidence and applicable benefit limits.

Provider Requirements & Prior Authorization

Prior Authorization

Prior authorization review process

Prior authorization and advance coverage determination requests are reviewed against applicable criteria — including CMS NCD/LCD, NHP/NHIC/NHAS internal medical policies, MCG, and UM delegated entity criteria — and are approved when criteria are met; if criteria are not met the request is referred to the Medical Director for denial determination or exception approval.

Reviews follow membership-specific sequence (see Commercial vs Medicare Advantage review sequences).
UM staff enter approvals into the authorization system or delegate entry to a Case Management Specialist.

Note

Collect the full set of required supporting records

UM Coordinators must collect a specified list of clinical and administrative records to support review and decision-making for authorization requests.

Office and hospital records; history of presenting problem; clinical exam; diagnostic testing results; treatment plans and progress notes.

Background & Policy Basis

The Utilization Management Department applies nationally recognized utilization criteria (for example, MCG) and CMS National and Local Coverage Determinations (NCD/LCD) to assess medical necessity for services. Clinical decision-making also considers patient-specific factors (age, comorbidities, treatment progress), the member's benefit documents, formulary and prior claims, and local delivery system capabilities. For Commercial membership, reviewers follow an ordered sequence of internal NHP/NHIC/NHAS medical policies, MCG, and delegated entity policies before consulting nationally published criteria or CMS guidance. For Medicare Advantage, reviewers apply CMS NCD/LCD first, then internal policies, MCG, and delegated policies; if specific criteria are unavailable, requests are reviewed using an experimental-process framework constrained by MA benefit limitations and supported by objective, evidence-based rationale.

Definitions & Utilization Criteria

Utilization Criteria — Definitions for nationally recognized and regionally developed clinical guidelines

DefinitionNationally recognized and regionally developed clinical guidelines (e.g., MCG, CMS NCD/LCD, internal medical policies, delegated entity criteria) used to determine medical necessity and authorization decisions.

Applied Sources for Medicare AdvantageCMS National and Local Coverage Determinations are applied to Medicare Advantage service requests and considered first when available.

Applied Sources for Commercial MembershipReview uses internally developed NHP/NHIC/NHAS medical policies, MCG, and UM delegated entity criteria; if unavailable, nationally published criteria and then CMS criteria are used.

Clinical Decision FactorsClinical decision-making considers patient-specific factors (age, comorbidities, complications, treatment progress, psychosocial situation, home environment) and member benefit documents, formulary, prior claims, and submitted clinical information.

Documentation RequirementUM Coordinators gather adequate medical information including office/hospital records, history, clinical exam, diagnostic results, treatment plans, progress notes, consultations, operative/pathology reports, and other relevant documentation.