Clinical Utilization Management Guidelines (CUMG) list
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This document lists the Clinical Utilization Management Guidelines adopted by Simply Healthcare Plans and Clear Health Alliance for Medicaid managed care in Florida and explains their use in prior authorization and medical necessity determinations.
No material clinical or coverage changes in this revision.
Clinical Utilization Management Guidelines Catalog
Catalog of CUMG titles
List of Clinical Utilization Management Guidelines (CUMG) titles and identifiers adopted for use in utilization management decisions; these guidelines are intended to guide medical necessity and prior authorization reviews.
How to Use CUMG for Medical Necessity and Referral
Use of CUMG for medical necessity — prior authorization, referral, and documentation
MCG care guidelines are used for medical necessity review for inpatient and certain outpatient services. Providers must submit prior authorization requests when required by the plan; if a request does not meet the established CUMG criteria it will be referred to a licensed physician reviewer with appropriate clinical expertise. Documentation supporting medical necessity should follow the Medicaid definition of medical necessity and the plan's Medical Necessity Criteria Policy.
- Submit prior authorization when required by the plan for inpatient, inpatient rehabilitation, skilled nursing facility reviews, and outpatient services where no other policy exists.
- If the request does not meet established CUMG criteria, the case will be referred to a licensed physician reviewer.
- Medical necessity determinations are made case-by-case per the Medicaid state contract, regulatory guidance, CMS requirements, or the plan's Medical Necessity Criteria Policy.
Key Definitions
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