Use of Clinical UM Guidelines for Prior Authorization

Highmark BCBS uses adopted Clinical Utilization Management (UM) Guidelines (including MCG Care Guidelines where applicable) as the primary framework for medical necessity review and for assessing site-of-service appropriateness. These guidelines inform inpatient, inpatient rehabilitation, skilled nursing facility, and certain outpatient service reviews when no specific Medical Policy or Clinical UM Guideline exists. Providers should reference the publicly available Medical Policy and Clinical UM Guidelines on the Highmark provider site when preparing requests.

• Clinical UM Guidelines are used for medical necessity review and site-of-service appropriateness.
• MCG Care Guidelines are applied for inpatient review and where no specific Medical Policy/Clinical UM Guideline exists, except where superseded by Medicaid state contracts, regulatory guidance, CMS requirements, or Highmark Medical Policy/Clinical UM Guidelines.
• Level of Care for Alcohol and Drug Treatment Referral 3.0 is used for substance abuse services per state requirements.

Referral to Physician Reviewer When Criteria Unmet

If a request does not meet established guideline criteria, the case will be referred to a licensed physician reviewer with appropriate clinical expertise for an individualized determination of medical necessity. Determinations are made case-by-case in accordance with the applicable Medicaid state contract, regulatory guidance, CMS requirements, or Highmark's Medical Necessity Criteria Policy (ADMIN.0004).

• Requests not meeting guideline criteria are escalated to a licensed physician reviewer.
• Medical necessity determinations follow Medicaid/CMS/state contract definitions and Highmark policy ADMIN.0004.

Prior Authorization: Explicit Triggers Not Specified Here

The excerpt does not list explicit prior authorization triggers, required forms, or an itemized list of services that automatically require prior authorization. Providers should not assume automatic approval or denial from this section alone and must consult the full Clinical UM Guidelines and applicable Medical Policies for specific authorization requirements.

• No explicit authorization or denial triggers are specified in the provided excerpt.
• Providers must consult the full guideline or Medical Policy pages for service-specific prior authorization requirements.

Medical Necessity Basis and Documentation Expectations

Providers should document clinical rationale and supporting records sufficient to demonstrate that care meets the applicable medical necessity criteria. Documentation should align with the definitions and requirements in the Medicaid state contract, regulatory guidance, CMS rules, and Highmark Medical Policy/Clinical UM Guideline expectations. Incomplete or insufficient documentation may delay review or result in denial.

• Expectations: supply complete clinical records, rationale, and any test results or prior treatments relevant to the medical necessity determination.
• Insufficient documentation can lead to delays or denial; submission should follow the referenced guidelines and state/CMS requirements.

Provider Actions — Summary

Provider action summary: consult the Clinical UM Guidelines on the Highmark provider site for service-specific criteria, prepare complete documentation tied to medical necessity criteria, and be aware that requests not meeting criteria will be escalated to a physician reviewer. Do not rely on this excerpt for service-level prior authorization rules; verify requirements on the published guideline or Medical Policy pages.

• Visit the Highmark provider Medical Policies and Clinical UM Guidelines page for guideline details and any New items or guideline titles.
• Prepare and submit complete clinical documentation when requesting authorization or filing for review.
• Expect escalation to a licensed physician reviewer if criteria are unmet.

Refer to specific DME Clinical UM Guidelines for documentation and coverage criteria

DME reviews are governed by the listed Clinical UM Guidelines (examples include Infant Home Apnea Monitors; Home Phototherapy for Neonatal Hyperbilirubinemia; Hospital Beds and Accessories; Pressure Reducing Support Systems; Home Oxygen Therapy; Therapeutic Shoes; External Infusion Pumps; Wheeled Mobility devices; Powered Wheelchairs; Electric Breast Pumps; Pediatric Gait Trainers; High Frequency Chest Compression Devices; Noninvasive Home Ventilator Therapy; and many others). Providers must refer to the specific DME guideline on the payer website for documentation expectations and coverage criteria when requesting DME.

• Numerous CG‑DME guidelines are listed; view each CG‑DME guideline for item‑specific documentation and coverage criteria.
• Use the payer website link to access full guideline text and any PA/coverage steps not shown in this inventory.

No coding or identifier details in this inventory chunk — consult guideline pages

Chunk 21 contains only guideline title entries (CG‑SURG series) and 'New item' markers; it does not provide coding, billing identifiers, or procedural codes. For coding or identifier details, providers must consult the individual Clinical UM Guideline pages or the payer's medical policy resources.