CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

May 2025 Clinical Utilization Management Guidelines

A bulletin listing Clinical Utilization Management Guidelines (CUMG) adopted by Highmark BCBS WNY for Medicaid Managed Care, HARP, Child Health Plus, and Essential Plan members; indicates many specific guideline codes/titles marked as 'New item'. Governs which CUMG documents have been adopted and where to find full guideline content.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyMay 2025 Clinical Utilization Management Guidelines

Policy CodePolicy N/A

Change TypeNew guideline adoptions (multiple)

Effective Date

Next Review Date

Key ActionProviders must consult the full Medical Policy and Clinical UM Guideline subsidiary website for each listed CUMG to determine specific medical necessity criteria and documentation requirements for MMC, HARP, CHPlus, and EP members.

SourceLink

POLICY UPDATE CHANGES

A large set of Clinical Utilization Management Guidelines were adopted and listed as 'New item' for Medicaid-related programs.

200+CUMG items listed

MMC/HARP/CHPlus/EPPrograms affected

Summary of Change Bulletin

Highmark BCBS WNY adopted a comprehensive list of Clinical Utilization Management Guidelines (CUMG) for use in medical necessity reviews and site-of-service determinations for Medicaid-related programs: MMC, HARP, CHPlus, and EP. Subject: Clinical Utilization Management Guidelines list (May 2025). Status: CURRENT. InterQual and MCG are used when no policy exists, and Medicaid state contracts, regulatory guidance and CMS requirements supersede external criteria.

Clinical Utilization Management Guidelines Adopted

Listed Clinical UM Guideline identifiers and titles (New items)mixed

CG-ADMIN-01	Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists
CG-ANC-03	Acupuncture
CG-ANC-04	Ambulance Services: Air and Water
CG-ANC-05	Ambulance Services: Ground; Emergent
CG-ANC-06	Ambulance Services: Ground; Nonemergent
CG-ANC-07	Inpatient Interfacility Transfers
CG-ANC-08	Mobile Device-Based Health Management Applications
CG-DME-03	Neuromuscular Stimulation in the Treatment of Muscle Atrophy
CG-DME-04	Transcutaneous Electrical Nerve Stimulation
CG-DME-05	Cervical Traction Devices for Home Use

1–10 of 231

1/24

The bulletin marks the listed CUMG entries as 'New item' and states that the Clinical Utilization Management Guidelines indicated as new were adopted by the Medical Operations Committee; this adoption is described in the bulletin and is a material change.

What Providers Must Do

Documentation Required

Reference full guideline for medical necessity determinations

Providers must consult the full Medical Policy and Clinical UM Guideline subsidiary website for each listed CUMG to determine specific medical necessity criteria and documentation requirements for MMC, HARP, CHPlus, and EP members.

Reminder: consult the full Medical Policy and Clinical UM Guideline subsidiary website for each CUMG listed to find specific medical necessity criteria and documentation requirements.

Prior Authorization

Prepayment medical necessity review usage

InterQual or MCG criteria will be used for medical necessity review when no other Clinical UM Guideline exists; Medicaid contract, regulatory guidance, CMS and Medical Policy/Clinical UM Guidelines supersede InterQual/MCG.

Note: InterQual/MCG are used when no CUMG exists; Medicaid state contracts, regulatory guidance, and CMS requirements supersede external criteria.

Denial Risk

Case-by-case physician review if criteria not met

If a request does not meet established criteria guidelines, cases will be referred to a licensed physician reviewer with appropriate clinical expertise and may be denied if not medically necessary per state/CMS definitions.

Cases not meeting criteria may be referred to a licensed physician reviewer and may be denied in accordance with state/CMS definitions of medical necessity.

Definitions & Scope

InterQual® Criteria or MCG Care Guidelines are used for medical necessity review (including inpatient and behavioral health), inpatient site-of-service appropriateness, rehabilitation and skilled nursing facility review, and for outpatient services or procedures where no established Medical Policy or Clinical UM Guideline exists. However, Medicaid state contracts, regulatory guidance, CMS requirements, and Highmark Medical Policy/Clinical UM Guidelines supersede MCG and InterQual when there is a conflict.

Term	Definition
CUMG	Clinical Utilization Management Guideline
MMC/HARP/CHPlus/EP	Medicaid Managed Care, Health and Recovery Plan, Child Health Plus, Essential Plan

Effective Actions & Next Steps

Immediate actions: providers must consult the full Medical Policy and Clinical UM Guideline subsidiary website for each listed CUMG to determine specific medical necessity criteria and documentation requirements; be aware that InterQual or MCG will be used only when no other Clinical UM Guideline exists; and note that the listed CUMGs are adopted for MMC/HARP/CHPlus/EP members. Effective date and next review date are not specified in the bulletin.

Quick reference

ProgramsMMC/HARP/CHPlus/EP

ReferenceClinical UM Guideline subsidiary website

Fallback criteriaInterQual/MCG

Policy statusCURRENT