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    OpenPayerPolicy UpdatesClinical/Medical PolicyCenCal Health UM Criteria Coverage | OpenPayer
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    CurrentCenCal HealthPolicy MM-UM22

    Clinical Criteria for Utilization Management Authorization Decisions

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    Governs the development, adoption, application, review, revision, and distribution of clinical criteria used for prospective, concurrent, and retrospective utilization review of Medi-Cal services.

    Policy Summary
    PayerCenCal Health
    PolicyClinical Criteria for Utilization Management Authorization Decisions
    Policy CodePolicy MM-UM22
    Change TypeRoutine reviewno material change
    Effective DateFebruary 1, 2011
    Next Review DateN/A
    Key ActionObtain advance approval for the amount, duration, and scope of non-emergent covered services.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3Utilization review settings covered
    5Approved criteria hierarchy levels
    6Individual member factors considered
    AnnualCriteria review frequency

    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.

    Provider/member
    Criteria disclosure recipients

    Clinical Criteria for Utilization Management

    Individualized Medical Necessity Review

    CenCal Health makes Utilization Management authorization decisions case by case based on the Medical Necessity of the requested health care service, using approved, written, objective criteria and/or guidelines supported by sound medical evidence and clinical principles.

    ALL of the following apply

    • The requested service meets the Medical Necessity standard

      • The service is reasonable 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.
      • The service is necessary to achieve age-appropriate growth and development or to attain, maintain, or regain functional capacity.
    • The applicable approved criteria and/or guidelines support the requested service and are applied consistently with the Utilization Management Program Description.

      Criteria must be objective, based on sound medical evidence, and developed with involvement from actively practicing health care providers.

    • The review accounts for the Member's unique health care needs and the characteristics of the local health care delivery system, including access to and availability of services.

    • Individual circumstances are considered

      • Age
      • Comorbidities
      • Complications
      • Progress of treatment
      • Psychosocial situation
      • Home environment, when applicable
    • The criteria are applied consistently to medical/surgical, mental health, and Substance Use Disorder services and benefits.

    Approved Criteria and Guideline Hierarchy

    For Medical Necessity determinations, CenCal Health uses the following hierarchy of approved, written criteria and/or guidelines, applying the highest applicable source first and considering the Member's individual circumstances and local access and availability.

    Approved criteria and guideline hierarchy

    • 1. California State criteria, including the California Medi-Cal Provider Manual, which addresses Medi-Cal services, programs, and claim reimbursement guidelines; and California Children's Services (CCS) Program criteria, guidelines, and numbered letters, when applicable.
    • 2. CenCal Health medical policies.
    • 3. Milliman Care Guidelines (MCG), including Behavioral Health Criteria.
    • 4. For physician-administered drugs, the Magellan Rx Management Library of Medical Necessity Criteria. These evidence-based clinical guidelines are based on medical literature, nationally recognized guidelines, practice observations, and database analyses, and are vetted through Magellan's Medical Necessity Criteria Committee and CenCal Health's Pharmacy & Therapeutics Committee.

    Medical Necessity Definition

    Medical Necessity is determined on a case-by-case basis, taking into account the individual needs of the Member. Medically Necessary services are reasonable and necessary services that meet the applicable purpose and functional-need criteria below.

    Medical Necessity assessment

    • The service is needed for at least one covered purpose

      • Protect life.
      • Prevent significant illness or significant disability.
      • Alleviate severe pain through the diagnosis or treatment of disease, illness, or injury.

    • The service supports an applicable health or functional need

      • Achieve age-appropriate growth and development.

    Utilization Management Requirements

    Prior Authorization

    Prior Authorization Required

    Obtain prior authorization before providing non-emergent Covered Services. Prior Authorization is the formal process requiring a Provider to obtain advance approval for the amount, duration, and scope of non-emergent Covered Services.

    • Obtain approval before delivering the applicable non-emergent Covered Services.
    • Prior authorization applies to the approved amount, duration, and scope of services.
    Note

    Use Approved UM Criteria

    CenCal Health uses approved, written UM criteria and/or guidelines that are objective, based on sound medical evidence and clinical principles, and consistent with the UM Program Description. Criteria are applied consistently and reviewed through the UM Committee and Quality Improvement and Health Equity Committee process, with approval at least annually and updates adopted as appropriate.

    • The criteria hierarchy may include California State criteria and Medi-Cal Provider Manual guidance, CenCal Health medical policies, Milliman Care Guidelines, and applicable Magellan Rx Management Library criteria for physician-administered drugs.

    Utilization Management Overview

    CenCal Health uses utilization management (UM) and utilization review (UR) to evaluate the medical necessity, appropriateness, and efficiency of health care services, procedures, and facilities. The policy establishes the process for developing, adopting, applying, reviewing, revising, and distributing the clinical criteria and guidelines used in utilization review decisions.

    Key Policy Definitions

    California Children's Services (CCS)-Eligible Condition
    Defined termCalifornia Children's Services (CCS)-Eligible Condition
    MeaningA medical condition that qualifies a child to receive medical services under the CCS Program.
    Regulatory referenceAs specified in 22 C.C.R. §41515.1 et seq.
    CCS Program
    Defined termCCS Program
    Program typeA state and county program.
    PurposeProvides medically necessary services to treat CCS-Eligible Conditions.
    Policy Summary
    PayerCenCal Health
    PolicyClinical Criteria for Utilization Management Authorization Decisions
    Policy CodePolicy MM-UM22
    Change TypeRoutine reviewno material change
    Effective DateFebruary 1, 2011
    Next Review DateN/A
    Key ActionObtain advance approval for the amount, duration, and scope of non-emergent covered services.
    SourceLink
    On This Page
    Clinical Criteria for Utilization ManagementUtilization Management RequirementsUtilization Management OverviewKey Policy Definitions
  1. 5. Guidelines from nationally recognized health care and professional organizations, including evidence-based clinical guidelines published by national entities such as the National Guideline Clearinghouse, National Institutes of Health, American College of Obstetricians and Gynecologists (ACOG), and other professional medical associations.
  2. Attain, maintain, or regain functional capacity.
  3. For a Member under 21 years of age, improve, support, or maintain the Member's current health condition.
  4. For Members less than 21 years of age, the service meets the EPSDT standard of Medical Necessity under 42 U.S.C. §1396d(r)(5), as required by Cal. W&I Code §§14059.5(b) and 14132(v).

    For children, the Plan must determine Medical Necessity case by case, taking into account the individual needs of the child. Services include those necessary to achieve or maintain age-appropriate growth and development and to attain, regain, or maintain functional capacity.

  5. Criteria and/or guidelines are monitored for updates and may be developed or revised with appropriate practitioner involvement.
  6. CenCal Health ensures consistent application of approved criteria through annual reviews and documents improvement actions when needed.
    7. Documentation Required

    Request the Applicable UM Criteria

    Providers may request the CenCal Health UM criteria and/or guidelines used in a decision by contacting the Plan's UM Department. Providers may request criteria for the specific procedures or conditions at issue; CenCal Health documents provider requests and may provide the materials electronically or charge reasonable copying and postage costs.

    • Criteria are disclosed to the Provider and Member when used as the basis to modify, delay, or deny services in a specified case under review.
    • Approved UM criteria and/or guidelines are available to the public upon request.
    • Contact the UM Department to request the applicable criteria or guidelines.
    Denial Risk

    Medical Necessity Requires Individualized Review

    CenCal Health determines medical necessity using approved written objective criteria and individualized review. When reviewing a request, CenCal Health considers the Member's unique health care needs, access and service availability, and relevant individual characteristics; a request may be authorized, modified, delayed, or denied based on that review.

    • Individualized considerations include age, comorbidities, complications, progress of treatment, psychosocial situation, and home environment when applicable.
    • Criteria are applied consistently across medical/surgical, mental health, and Substance Use Disorder services and benefits.
    • Access and availability standards and the characteristics of the local health care delivery system are considered when determining medical necessity.
    Covered Services
    Defined termCovered Services
    DescriptionHealth care services identified under applicable California laws and regulations, including the Welfare and Institutions Code and California Code of Regulations.
    Additional sourcesIncludes the Medi-Cal Provider Manual, California Medicaid State Plan, California Section 1115 Medicaid Demonstration Project, the Plan's contract with DHCS, and applicable DHCS authorities and APLs.
    Medically Necessary or Medical Necessity
    Defined termMedically Necessary or Medical Necessity
    Core standardReasonable and necessary services to protect life, prevent significant illness or significant disability, or alleviate severe pain through diagnosis or treatment of disease, illness, or injury.
    Functional and developmental needsServices must support age-appropriate growth and development and the attainment, maintenance, or recovery of functional capacity.
    Members under 21Services must meet the EPSDT medical necessity standard and may include services necessary to improve, support, or maintain the member's current health condition.
    Determination processMedical necessity is determined case by case, taking into account the individual needs of the child.
    Member
    Defined termMember
    Eligibility statusA Medi-Cal recipient.
    ResidenceResides in the Plan's Service Area.
    EnrollmentIs enrolled with the Plan.
    Prior Authorization
    Defined termPrior Authorization (PA)
    ProcessA formal process requiring a provider to obtain advance approval.
    Services coveredApplies to non-emergent Covered Services.
    Approval scopeAdvance approval addresses the amount, duration, and scope of the services.
    Utilization Management (UM) or Utilization Review (UR)
    Defined termUtilization Management (UM) or Utilization Review (UR)
    Medical necessityEvaluation of the medical necessity of health care services, procedures, and facilities.
    AppropriatenessEvaluation of the appropriateness of their use.
    EfficiencyEvaluation of the efficiency of their use.