Clinical Criteria for Utilization Decisions Desk Procedure
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Describes how the Utilization Management department applies nationally recognized and regionally developed utilization criteria and medical policies to prior authorization and coverage determinations for members, including Medicare Advantage, and how UM staff and medical leadership review and apply those criteria.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Application of criteria for approvals
Approve services when applicable criteria are met and enter authorization; if criteria are not available, follow the documented fallback order.
Applies to Commercial and Medicare Advantage with Medicare restricted to CMS NCD/LCDs and Evidence of Coverage limits
Authorization exceptions and Medical Director review
When requests do not meet established criteria or present special circumstances.
Board-certified consultants may be engaged when additional expertise is required
If specific criteria are not available for the requested service, the Utilization Management (UM) review will evaluate the request using the documented fallback process: first apply NHP/NHIC/NHAS internally developed medical policies and MCG; for delegated services, follow the UM delegated entity policies; if those are not available, consider commercially published criteria and then CMS National and Local Coverage Determinations. When no specific criteria exist, the request will be reviewed based on the experimental/technology assessment process and the Medicare Advantage member’s benefit limitations, and the reviewer will provide an objective, evidence-based rationale citing authoritative evidence to support the determination.
Requests that do not meet CMS, commercial, or regionally developed medical criteria are referred to a Medical Director (or Chief Medical Officer) for review. Following Medical Director review, services that remain unsupported by applicable criteria or evidence are subject to denial; the Medical Director may instead approve an exception when clinical circumstances and supporting evidence justify it.
Regulatory and Coding References
| Sec 422.101 (b)(1)-(5) | Code of Federal Regulations reference |
| Sec 422.112(a)(6)(ii) | Code of Federal Regulations reference |
| Sec 422.152 (b)(1),(4) | Code of Federal Regulations reference |
| Sec 422.202(b) and (c) | Code of Federal Regulations reference |
| Sec 422.504 (a)(3)(iii) | Code of Federal Regulations reference |
Provider Responsibilities and Prior Authorization Process
Prior authorization intake and routing to UM workflow
Prior authorization and advance coverage determination requests are date-stamped in the UM information system and forwarded to the appropriate UM Coordinator or entered into the UM system for routing. The UM Coordinator then gathers clinical information and reviews the request against applicable internal policies, MCG, delegated entity criteria or CMS NCD/LCDs as appropriate.
- Electronic UM system date-stamps each request and forwards to the appropriate UM Coordinator or enters the request into the UM information system.
- UM Coordinator gathers clinical information and applies applicable clinical review criteria, internal policies, MCG, delegated entity criteria or CMS NCD/LCDs.
Operational steps for UM triage and coordination
UM triage coordinators and UM Coordinators must collect adequate clinical information and make reasonable attempts to obtain missing essential information from ordering/rendering practitioners or the member, and then apply clinical criteria considering individual patient characteristics during review.
- Gather the listed clinical documentation (see Required clinical documentation callout).
- Make reasonable and sufficient attempts to obtain additional information if essential information is incomplete by contacting ordering/rendering practitioners and/or the member.
Required clinical documentation to support review
Providers must supply adequate medical information to facilitate decision making; the UM Coordinator may require specific records and supporting materials to review a request.
- Office and hospital records
- History of presenting problem and clinical exam findings
- Diagnostic testing results
- Treatment plans, progress notes, consults, and operative/pathology reports
- Rehabilitation evaluations and photographs
- A printed copy of criteria related to the request
- Information regarding benefits, local delivery system, patient characteristics, and information from responsible family members
Refer criteria-nonconforming requests to Medical Director for denial review
Requests that do not meet CMS, commercial, or regionally developed medical criteria are referred to a Medical Director (or Chief Medical Officer) for determination of denial or approval with exception.
- Medical Director/Chief Medical Officer may authorize care not meeting standard criteria based on individual circumstances.
- UMC refers requests not meeting criteria to Medical Director for denial determination or exception approval.
Background and Policy Scope
The UM department uses nationally recognized criteria, internal medical policies, delegated-entity policies and CMS National and Local Coverage Determinations to evaluate medical necessity. UM staff review requests against NHP/NHIC/NHAS internally developed medical policies and MCG, apply delegated entity criteria when applicable, and consider commercially published criteria. For Medicare Advantage determinations the department applies CMS NCD/LCD guidance and the member’s Evidence of Coverage limits. The Chief Medical Officer or Medical Director may authorize care outside standard criteria based on individual patient age, comorbidities, complications or other circumstances and may consult board-certified specialists when additional expertise is required.
Key Definitions and References
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