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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyCenCal Health UM Criteria Prior Auth | OpenPayer
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    ModifiedCenCal HealthPolicy HS-UM22

    Clinical Criteria for Utilization Management Authorization Decisions

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    Governs the development, adoption, application, review, revision, and disclosure of clinical criteria used for prospective, concurrent, and retrospective utilization review for Medi-Cal and D-SNP members.

    Policy Summary
    PayerCenCal Health
    PolicyClinical Criteria for Utilization Management Authorization Decisions
    Policy CodePolicy HS-UM22
    Change TypeAdministrative revisionno material clinical or coverage change
    Effective DateFebruary 1, 2011
    Next Review DateN/A
    Key ActionObtain prior authorization before providing non-emergent covered services.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Lines of business covered
    3Utilization review types covered
    6Member factors considered
    AnnualCriteria review frequency
    On request

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    Criteria availability

    Medical Necessity and Criteria Application

    Core medical necessity and UM decision standards

    CenCal Health authorizes, modifies, or denies services using an individualized medical-necessity review and approved, objective criteria or guidelines.

    Core UM decision requirements: The requested service must be a Covered Service or otherwise evaluated under the applicable benefit and coverage requirements; the decision must be based on Medical Necessity; and the criteria or guidelines applied must be approved, written, objective, and supported by sound medical evidence, sound clinical principles, and evidence-based practice.

    These standards apply to prospective, concurrent, and retrospective utilization review and to authorization, modification, and denial decisions. Criteria are developed with actively practicing health care provider involvement, reviewed at least annually, and disclosed as required.

    Individualized medical necessity review

    When applying criteria to an individual member, CenCal Health considers all of the following member-specific factors.

    Individualized application of criteria: The member's age, comorbidities, complications, progress of treatment, psychosocial situation, and home environment when applicable must be considered.

    CenCal Health also considers the member's unique health care needs, local access and availability of services, and applicable access and availability standards when determining medical necessity.

    Line-of-business criteria hierarchy

    The applicable hierarchy of approved criteria and guidelines depends on the member's line of business.

    Medi-Cal criteria hierarchy

    • Department of Health Care Services Medi-Cal Provider Manuals and Bulletins.
    • Medi-Cal All Plan Letters.
    • California Children's Services criteria, guidelines, and Numbered Letters, when applicable.
    • CenCal Health medical policies, when applicable.
    • MCG Guidelines, including Behavioral Health, General Recovery Care, Ambulatory Care, Recovery Facility Care, and Home Care modules.

    D-SNP criteria hierarchy

    D-SNP criteria when Medicare coverage is not fully established

    When Medicare coverage criteria are not fully established for a D-SNP service, internal coverage criteria may supplement or interpret the applicable Medicare provisions.

    D-SNP internal coverage criteria: Internal criteria must be based on current evidence in widely used treatment guidelines or qualifying clinical literature, including large randomized controlled trials or prospective cohort studies with clear results published in peer-reviewed journals and specifically designed to answer the relevant clinical question, or large systematic reviews or meta-analyses addressing that specific clinical question.

    D-SNP criteria are applied to the extent possible using Medicare statutes, regulations, National Coverage Determinations, and Local Coverage Determinations. CenCal Health discloses the internal criteria, evidence summary, evidence sources, and rationale supporting adoption as required.

    CenCal Health will not make payment for any health care item, service, or drug furnished, ordered, or prescribed by an individual or entity included on the applicable Medicare preclusion list, in accordance with 42 C.F.R. §§ 422.222 and 422.224.

    Authorization and Provider Requirements

    Prior Authorization

    Advance Approval Required for Non-Emergent Services

    Obtain prior authorization (advance approval) before providing non-emergent Covered Services when required. The authorization addresses the amount, duration, and scope of the requested service.

    • Prior authorization applies to non-emergent Covered Services.
    • Approval must be obtained in advance of service delivery and must address the requested service's amount, duration, and scope.
    Documentation Required

    Clinical Information for D-SNP Determinations

    For D-SNP Medical Necessity determinations, CenCal Health considers coverage and benefit criteria, Medicare reasonableness and necessity requirements, the Member's medical history, physician recommendations, and clinical notes. Medical director involvement may be included when appropriate.

    • Provide or document the Member's medical history.

    Policy Terms and Standards

    Active Course of Treatment
    DefinitionA course of treatment in which a patient is actively seeing the provider and following the course of treatment.
    Patient involvementThe patient is actively seeing the provider.
    Treatment participationThe patient is following the prescribed course of treatment.
    California Children's Services (CCS)-Eligible Condition
    DefinitionA medical condition that qualifies a child to receive medical services under the California Children's Services Program.
    Eligible individualThe condition must qualify a child for CCS medical services.
    Policy Summary
    PayerCenCal Health
    PolicyClinical Criteria for Utilization Management Authorization Decisions
    Policy CodePolicy HS-UM22
    Change TypeAdministrative revisionno material clinical or coverage change
    Effective DateFebruary 1, 2011
    Next Review DateN/A
    Key ActionObtain prior authorization before providing non-emergent covered services.
    SourceLink
    On This Page
    Medical Necessity and Criteria ApplicationAuthorization and Provider RequirementsPolicy Terms and Standards
  1. Medicare National Coverage Determinations and Medicare Local Coverage Determinations, including the applicable Medicare contractor criteria for California.
  2. Medicare manuals, including applicable Internet Only Manuals and Medicare Managed Care Manual provisions.
  3. CenCal Health medical policies.
  4. MCG Guidelines, including Inpatient and Surgical Care, General Recovery Care, Ambulatory Care, Behavioral Health Care, Recovery Facility Care, Home Care, and Medicare Compliance modules.
  5. For physician-administered drugs, the Prime Therapeutics Management Library of Medical Necessity Criteria.
  6. Nationally recognized evidence-based guidelines from health care and professional organizations.
  7. Include physician recommendations and relevant clinical information or notes.
  8. Determinations also consider applicable coverage and benefit criteria and Section 1862(a)(1) of the Social Security Act.
    9. Denial Risk

    Payment Denied for Precluded Providers or Entities

    CenCal Health will not make payment for a health care item, service, or drug furnished, ordered, or prescribed by an individual or entity included on the Medicare preclusion list, consistent with 42 C.F.R. §§ 422.222 and 422.224.

    • Verify that the furnishing, ordering, or prescribing provider or entity is not on the Medicare preclusion list.
    • Payment is denied when the item, service, or drug is furnished, ordered, or prescribed by a precluded provider or entity.
    Governing program
    Eligibility is under the California Children's Services Program, as specified in 22 C.C.R. §41515.1 et seq.
    CareConnect or D-SNP Plan
    DefinitionCenCal Health's dual-eligible special needs plan for Medicare/Medi-Cal beneficiaries.
    Medicare coverageThe plan serves beneficiaries eligible for Medicare.
    Medi-Cal coverageThe plan also serves beneficiaries eligible for Medi-Cal.
    Covered Services
    DefinitionHealth care services that are made the responsibility of the D-SNP or Medi-Cal Plan.
    D-SNP responsibilityServices may be the responsibility of the D-SNP under CenCal Health's contract with CMS.
    Medi-Cal responsibilityServices may be the responsibility of the Medi-Cal Plan under CenCal Health's contract with DHCS.
    Local Coverage Determination (LCD)
    DefinitionA decision by a Medicare Administrative Contractor about whether a specific medical service, procedure, or item will be covered under Medicare within its geographic area.
    Decision makerThe decision is made by a Medicare Administrative Contractor.
    Geographic scopeThe determination applies within the contractor's geographic area.
    Medi-Cal Plan
    DefinitionCenCal Health's plan for Medi-Cal beneficiaries.
    Plan sponsorThe plan is operated by CenCal Health.
    BeneficiariesThe plan serves Medi-Cal beneficiaries.
    Medically Necessary or Medical Necessity
    Core standardReasonable and necessary to protect life, prevent significant illness or significant disability, or alleviate severe pain through the diagnosis or treatment of disease, illness, or injury.
    Medi-Cal developmental standardFor Medi-Cal members, services must also be necessary to achieve age-appropriate growth and development and attain, maintain, or regain functional capacity.
    Clinical purposeThe standard applies to diagnosis or treatment of disease, illness, or injury.
    EPSDT Medical Necessity
    Applicable membersApplies to Medi-Cal members under age 21.
    Case-by-case reviewThe Plan must determine medical necessity case by case, taking into account the individual needs of the child.
    Covered needsServices may be necessary to achieve or maintain age-appropriate growth and development, attain, regain, or maintain functional capacity, or improve, support, or maintain the child's current health condition.
    National Coverage Determination (NCD)
    DefinitionA nationwide decision made by CMS that determines whether a specific medical service, procedure, or item will be covered under Medicare.
    Decision makerThe decision is made by the Centers for Medicare & Medicaid Services (CMS).
    Geographic scopeThe determination is nationwide.
    Not Fully Established
    DefinitionD-SNP coverage criteria are not fully established when additional, unspecific criteria are needed to interpret or supplement general Medicare coverage provisions to determine medical necessity consistently.
    Flexible Medicare criteriaThe criteria are not fully established when an NCD or LCD expressly allows coverage beyond the specific listed indications.
    No applicable criteriaThe criteria are not fully established when no applicable Medicare statute, regulation, NCD, or LCD sets forth coverage criteria.
    Prior Authorization
    DefinitionA formal process requiring a provider to obtain advance approval for the amount, duration, and scope of non-emergent Covered Services.
    Who obtains approvalThe provider must obtain the advance approval.
    Services coveredThe process applies to non-emergent Covered Services.
    Utilization Management or Utilization Review
    DefinitionThe evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities.
    Medical necessityThe review evaluates whether the use of care is medically necessary.
    Review dimensionsThe review also evaluates appropriateness and efficiency.
    Substance Use Disorders
    DefinitionDisorders set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
    Reference publicationThe definition uses the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
    PublisherThe manual is published by the American Psychiatric Association.