Pre-payment review uses the CUMG (CG-ADMIN-01 precedence)

Pre-payment review and medical necessity determinations are performed using Simply's Clinical Utilization Management Guidelines (CUMG). When no other clinical UM guideline exists, CG-ADMIN-01 (Clinical Utilization Management Guideline for Pre-Payment Review Medical Necessity Determinations) is used to guide pre-payment review.

• MCG Care Guidelines are used only where no other clinical UM guideline exists for certain inpatient and outpatient reviews and are superseded by Medicaid state contracts, regulatory guidance, CMS requirements, and Simply's Medical Policy/Clinical UM Guidelines.
• Requests that do not meet established criteria will be referred to a licensed physician reviewer for determination.

CUMG index only — no explicit PA criteria listed

This section is an index that enumerates CUMG identifiers and titles (several items are marked “New”) rather than listing specific prior authorization criteria.

• The listing presents CUMG number and title pairs (e.g., CG-ADMIN-01) and flags new items where applicable.
• Providers must refer to the individual CUMG document for any specific authorization requirements.

Provider note: index of guidelines — consult individual CUMG for requirements

Providers should note that this document is an index of adopted CUMG items and that specific clinical or authorization requirements are contained in each individual guideline; consult the referenced guideline for required actions when submitting requests.

• The index lists CUMG identifiers and titles (many across specialties) but does not itself define authorization criteria.
• When submitting requests, reference the applicable CG-DME guideline for equipment-specific requirements and documentation standards.

Follow each CG-DME guideline for actionable requirements

Supplementary provider-facing instructions: this listing does not replace the full CG-DME guideline documents; providers must follow the specific CG-DME guideline for clinical criteria, documentation, and any authorization or rental/purchase rules.

• The document enumerates many CG-DME guideline identifiers and titles; equipment-specific rules (rental vs purchase, replacement intervals) are defined within each CG-DME guideline.
• If no specific CG-DME exists for a requested service, CG-ADMIN-01 guides pre-payment review.

Document medical necessity per Medicaid/CMS/ADMIN.00004 and the specific CG-DME

Medical necessity determinations are made on a case-by-case basis according to the definition of medical necessity contained within the Medicaid state contract, regulatory guidance, CMS requirements, or Simply's Medical Necessity Criteria Policy ADMIN.00004; refer to each CG-DME for item-specific documentation requirements.

• The CUMG list points to separate guideline documents that detail documentation requirements per equipment type (e.g., CG-DME-03, CG-DME-15, CG-DME-31).
• Providers must supply the documentation specified in the applicable CG-DME when requesting authorization or coverage determinations.

Sign up for provider communications for timely updates

Providers and members are encouraged to sign up to receive email updates (including some communications sent in lieu of fax or mail) via the QR code or online form at https://bit.ly/signup-sml-fl to receive timely policy and guideline notices.

• Email is the quickest way to receive important information from Simply; sign-up is optional and not a billing or documentation requirement.

Denial risk if request does not meet guideline criteria

Requests that do not meet the established guideline criteria will be referred to a licensed physician reviewer with appropriate clinical expertise and may be denied if the medical necessity definition criteria are not met.

• Nonconforming requests may result in denial following physician review.
• Providers should ensure submissions conform to the applicable CUMG or, if none exists, to CG-ADMIN-01 to avoid referral and potential denial.

Index only — no explicit authorization/denial criteria in this listing

This document functions as an index of CUMG items and does not itself provide explicit authorization or denial criteria; providers must consult the referenced guideline for actionable authorization rules.

• The listing enumerates CUMG numbers and titles (some marked New) but contains no explicit coverage or denial logic.
• For authorization decisions, use the applicable CG-DME or CG-ADMIN-01 when no other guideline exists.

Follow the CG‑DME guideline for equipment‑specific documentation

Refer to the specific CG‑DME guideline identified for the equipment being requested to determine the exact documentation required (e.g., CG‑DME‑03, CG‑DME‑15, CG‑DME‑31).

• Each CG‑DME guideline contains the equipment‑specific clinical criteria and documentation checklist providers must supply for authorization.
• Rental vs. purchase rules and replacement intervals are defined within the applicable CG‑DME guideline.

Communications sign‑up is optional (not a billing requirement)

Signing up for email communications is optional and intended for timely updates; it is not a billing or documentation requirement for claims or authorizations.

• Use the QR code or https://bit.ly/signup-sml-fl to enroll; enrollment does not change documentation or billing obligations.