CurrentPHC CaliforniaPolicy N/A

PHC-CA Clinical Criteria and Guidelines

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This policy governs how PHC California establishes, approves, applies, documents, and monitors clinical criteria and guidelines used for utilization management and coverage decisions across medical/surgical, behavioral health, and substance use disorder services.

Policy Summary

PayerPHC California

PolicyPHC-CA Clinical Criteria and Guidelines

Policy CodePolicy N/A

Change TypeRevision — no material clinical or coverage change

Effective DateDecember 31, 2017

Next Review DateN/A

Key ActionPrior authorization determinations must document the utilization review criteria and guidelines cited in the authorization case notes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

AnnualCriteria review and approval

9Decision-making factors

AnnualReviewer reliability testing

3Service categories

Clinical Criteria and Governance

Policy Summary

PayerPHC California

PolicyPHC-CA Clinical Criteria and Guidelines

Policy CodePolicy N/A

Change TypeRevision — no material clinical or coverage change

Effective DateDecember 31, 2017

Next Review DateN/A

Key ActionPrior authorization determinations must document the utilization review criteria and guidelines cited in the authorization case notes.

SourceLink

On This Page

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CurrentPHC CaliforniaPolicy N/A

PHC-CA Clinical Criteria and Guidelines

Customize your policy alerts

Sign up for all phccalifornia policy alerts

Know when phccalifornia releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerPHC California

PolicyPHC-CA Clinical Criteria and Guidelines

Policy CodePolicy N/A

Change TypeRevision — no material clinical or coverage change

Effective DateDecember 31, 2017

Next Review DateN/A

Key ActionPrior authorization determinations must document the utilization review criteria and guidelines cited in the authorization case notes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

AnnualCriteria review and approval

9Decision-making factors

AnnualReviewer reliability testing

3Service categories

Clinical Criteria and Governance

Policy Summary

PayerPHC California

PolicyPHC-CA Clinical Criteria and Guidelines

Policy CodePolicy N/A

Change TypeRevision — no material clinical or coverage change

Effective DateDecember 31, 2017

Next Review DateN/A

Key ActionPrior authorization determinations must document the utilization review criteria and guidelines cited in the authorization case notes.

SourceLink

On This Page

Evidence-based UM decision-making factors

Clinical criteria and guidelines used for utilization management decisions must be evidence-based or supported by professional consensus and must account for the enrolled population and the individual member.

Evidence base and population considerations: Criteria and guidelines are based on reasonable local or national medical evidence or the consensus of health care professionals. They consider the needs of the enrolled population, including geographic and cultural factors and the availability of network services.

Individual member and care-delivery factors: Decision-making considers age, comorbidity, complications or complexity of the member’s SNP membership, psychosocial factors, home environment, social determinants of health, availability of services, benefit coverage, and compliance concerns related to the treatment plan or medication adherence.

Approved criteria sources and governance

The Health Plan and its delegates must use approved utilization review criteria and guidelines and follow the established review, approval, implementation, and oversight process.

Approved criteria sources: Utilization review may use the Medi-Cal Provider Manual; nationally recognized evidence-based criteria such as InterQual or Milliman Care Guidelines (MCG); National Comprehensive Cancer Network (NCCN) Guidelines; specialty-society guidelines; Centers of Excellence Guidelines; preventive-health guidelines; behavioral-health Clinical Practice Guidelines; SAMHSA.gov; benefit structure and guidelines; National Institutes of Health (NIH) Guidelines; Centers for Disease Control and Prevention (CDC) Guidelines; and peer-reviewed literature.

This list is not exhaustive.

Review and approval: Criteria and guidelines are reviewed and updated annually or as appropriate, with recommended criteria submitted to the Utilization Management Committee (UMC) for review and approval. On an annual basis, the Director of Care Coordination or designee submits criteria and guidelines to the UMC and Quality Improvement and Health Equity Committee (QIHEC) for review and approval.Annual review and approval

Implementation and delegate oversight: After approval by the UMC and QIHEC, the UM team adopts and implements the approved criteria in the UM Program. Utilization Management Leadership distributes the criteria to the Plan and delegate professional reviewers, activates them in the UM systems, and makes them available to Members and Providers upon request. Delegated entities must submit their utilization review criteria and guidelines to the Health Plan for annual approval and adopt and implement evidence-based criteria under the Health Plan’s delegation agreement.

Delegate requirements are governed by the Health Plan’s Delegation Oversight Policy and UM Delegation Agreement.

Prior Authorization Documentation

Documentation Required

Apply Approved Criteria to Prior Authorization

Apply the utilization review criteria and guidelines approved by the appropriate committees to every prior authorization determination. Document the criteria and guidelines used to support each determination.

Documentation Required

Cite Criteria in Authorization Case Notes

Identify the specific utilization review criteria and guidelines cited for each prior authorization determination in the authorization case notes.

Policy Context

PHC California uses evidence-based clinical criteria and practice guidelines to promote consistent utilization management and coverage decisions. These criteria support authorization determinations for covered services and supplies and are based on local or national medical evidence, professional consensus, applicable benefit requirements, and recognized clinical guidance. The criteria are reviewed through the Health Plan’s governance process, adopted into the utilization management program, and implemented in applicable systems and workflows.

When making utilization management decisions, reviewers consider the enrolled population and individual member circumstances, including age, comorbidities, psychosocial factors, home environment, social determinants of health, service availability, benefit coverage, and treatment-plan or medication-adherence concerns. The approach applies consistently across medical/surgical, behavioral health, and substance use disorder services and benefits.