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    v1.0.31
    OpenPayerPolicy UpdatesClinical/Medical PolicyPHC California Clinical Criteria Update | OpenPaye…
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    CurrentPositive Healthcare (PHC) CaliforniaPolicy UM 135.3

    PHP Clinical Criteria and Guidelines

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    Governs how the Health Plan establishes, approves, applies, documents, monitors, and updates clinical criteria and guidelines for utilization management, organizational determinations, and coverage or denial decisions across medical/surgical, behavioral health, and substance use disorder services.

    Policy Summary
    PayerPositive Healthcare (PHC) California
    PolicyPHP Clinical Criteria and Guidelines
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective Date11/1/2018
    Next Review DateNot specified
    Key ActionDocument the utilization review criteria and guidelines used for organizational determinations and cite them in clear denial rationales.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    AnnualCriteria review cycle
    9Individual and service factors considered
    10Evidence and benefit source categories
    2Review and approval committees
    All
    Policy Summary
    PayerPositive Healthcare (PHC) California
    PolicyPHP Clinical Criteria and Guidelines
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective Date11/1/2018
    Next Review DateNot specified
    Key ActionDocument the utilization review criteria and guidelines used for organizational determinations and cite them in clear denial rationales.
    SourceLink
    On This Page
    Clinical Criteria and Guideline RequirementsDocumentation and Denial RationalePolicy Framework

    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.

    Professional reviewers assessed annually

    Clinical Criteria and Guideline Requirements

    Evidence-based and individualized UM decision-making

    Utilization management criteria and practice guidelines must be evidence-based, population-sensitive, developed with provider input, and applied to the individual member and care circumstances.

    Evidence-based and individualized decision-making

    • Evidence and population basis

      • Evidence or professional consensus: Base criteria and practice guidelines on reasonable local and national medical evidence or the consensus of health care professionals in the field.
      • Enrolled population needs: Consider the needs of the enrolled population, including factors specific to the geographic region, cultural makeup, and availability of network services.
      • Provider input: Develop criteria and practice guidelines in consultation with contracted community-facing providers.

    • Minimum individual and service considerations

      • Age
      • Comorbidity
      • Complications or complexity of the SNP membership
      • Psychosocial factors
      • Home environment
      • Social determinants of health
      • Availability of services, including skilled, home health, and inpatient services

    Approval, adoption, and consistent application

    Criteria and guidelines used for utilization review must be approved, adopted, consistently applied, and reviewed or updated through the required governance process.

    • Conduct utilization review using criteria and guidelines approved and adopted in the Utilization and Care/Case Management Program.
    • Ensure UM policies, processes, strategies, evidence-based standards, and other factors used for utilization management or utilization review are consistently applied.
    • Review and update criteria and guidelines annually or as appropriate.Annual review and update

    • Plan review and approval

      • Submit criteria and guidelines to the Utilization Management Committee for review and approval.

    Provide criteria upon member or physician request

    The Health Plan and its utilization management delegates must make the criteria used in UM decisions available upon request.

    Criteria disclosure

    • Upon request by a member or treating physician, provide orally or in writing all criteria used in making the utilization management decision.
    • Include discharge criteria, continued-stay criteria, and clinical practice guidelines when applicable.

    Documentation and Denial Rationale

    Documentation Required

    Document criteria supporting determinations

    Document the Utilization Review criteria and guidelines used for Organizational Determinations. For denials, provide a clear rationale that cites the applicable criteria.

    Denial Risk

    Cite criteria and rationale for denials

    Any Organizational Determination denying requested services or supplies must include a clear rationale citing the Utilization Review criteria and guidelines used.

    Policy Framework

    This policy establishes a framework for evidence-based clinical criteria and practice guidelines used in utilization management, organization determinations, and coverage or denial decisions. The framework applies across medical/surgical, behavioral health, and substance use disorder services and benefits, and is intended to ensure that decisions remain consistent with the Health Plan’s Utilization and Care/Case Management Program.

    Criteria and guidelines must reflect reasonable local and national medical evidence or professional consensus, be developed with contracted community-facing providers, and account for the enrolled population and individual care circumstances. Relevant factors include age, comorbidities, clinical complexity, psychosocial and home factors, social determinants of health, service availability, benefit coverage, and treatment or medication adherence. The policy also requires ongoing governance, implementation, and annual review of the criteria used in utilization review.

    Benefit coverage
  1. Compliance concerns, including treatment-plan and medication adherence
    2. Submit criteria and guidelines to the Quality Improvement Health Equity Committee for review and approval.
  2. After approval by the Utilization Management Committee and Quality Improvement Health Equity Committee, adopt and implement the approved criteria in the UM Program.
  3. Distribute the criteria and guidelines to Health Plan and delegate professional reviewers.
  4. Activate the criteria and guidelines in the UM systems.
  5. Require delegated entities to submit their utilization review criteria and guidelines to the Plan for annual approval and to adopt and implement evidence-based criteria under the delegation agreement.