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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyWellpoint Clinical UM Guidelines Update | OpenPaye…
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    ModifiedWellpointPolicy ADMIN.00004

    Clinical Utilization Management Guidelines

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    Applies to providers serving Wellpoint Washington Medicaid members and explains how medical necessity, site-of-service, and related utilization reviews are conducted using applicable policies, InterQual, MCG, or ASAM criteria.

    Policy Summary
    PayerWellpoint
    PolicyClinical Utilization Management Guidelines
    Policy CodePolicy ADMIN.00004
    Change TypeModified — new guidelines identified
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit requests with information sufficient for case-by-case medical necessity review under the applicable Medicaid state contract, regulatory guidance, CMS requirements, or Medical Necessity Criteria Policy.
    SourceLink
    POLICY UPDATE CHANGES

    The document identifies newly adopted Clinical Utilization Management Guidelines for Medicaid members, including specifically marked new guidelines.

    WA MedicaidJurisdiction and line of business
    13 pagesDocument length
    4Guidelines marked New
    Case-by-caseMedical necessity approach
    InterQual, MCG, ASAMReview criteria referenced
    3Guideline families

    Policy Scope and Guideline Framework

    This document is an administrative catalog of Clinical Utilization Management Guidelines adopted by Wellpoint Washington for Medicaid members. The guidelines support quality care and help reduce inappropriate use of medical resources across inpatient, outpatient, behavioral health, durable medical equipment, laboratory, imaging, rehabilitation, and surgical services.

    Medical Necessity and Service-Specific Review

    Case-by-case medical necessity review

    Medical necessity is determined case by case under the applicable controlling authority.

    Controlling requirements: Apply the definition of medical necessity in the applicable Medicaid state contract, regulatory guidance, CMS requirements, or Medical Necessity Criteria Policy ADMIN.00004.

    Medicaid state contracts, regulatory guidance, CMS requirements, and Wellpoint Medical Policies or Clinical UM Guidelines supersede MCG Care Guidelines and InterQual Criteria.

    Service-specific review criteria

    Use the listed criteria for the applicable service category.

    Policy Summary
    PayerWellpoint
    PolicyClinical Utilization Management Guidelines
    Policy CodePolicy ADMIN.00004
    Change TypeModified — new guidelines identified
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit requests with information sufficient for case-by-case medical necessity review under the applicable Medicaid state contract, regulatory guidance, CMS requirements, or Medical Necessity Criteria Policy.
    SourceLink
    On This Page
    Policy Scope and Guideline FrameworkMedical Necessity and Service-Specific ReviewUtilization Review Requirements

    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.

    Applicable review criteria: Use InterQual Criteria or MCG Care Guidelines for medical and behavioral health inpatient review, inpatient site-of-service appropriateness, inpatient rehabilitation, skilled nursing facility review, and outpatient services or procedures when no established Medical Policy or Clinical UM Guideline exists; use American Society of Addiction Medicine criteria for substance use disorder services according to state requirements.

    The applicable Medicaid contract, regulatory guidance, CMS requirements, and Wellpoint Medical Policies or Clinical UM Guidelines remain controlling.

    Utilization Review Requirements

    Note

    Use InterQual or MCG When Applicable

    Use InterQual® Criteria or MCG Care Guidelines when applicable to conduct medical necessity and site-of-service reviews.

    • Medical and behavioral health inpatient review
    • Inpatient site-of-service appropriateness
    • Inpatient rehabilitation and skilled nursing facility review
    • Outpatient services or procedures when no established Medical Policy or Clinical UM Guideline applies
    Note

    Apply ASAM Criteria

    Use American Society of Addiction Medicine® (ASAM) criteria for substance use disorder services according to applicable state requirements.

    Billing Rule

    Follow Controlling Authority

    Apply the controlling authority in the required order when conducting utilization review. Medicaid state contracts, regulatory guidance, and CMS requirements supersede Wellpoint Medical Policies and Clinical UM Guidelines, which in turn supersede MCG Care Guidelines and InterQual Criteria.

    • Medicaid state contracts
    • Regulatory guidance
    • CMS requirements
    • Wellpoint Medical Policies and Clinical UM Guidelines
    • MCG Care Guidelines and InterQual Criteria
    Note

    Determine Medical Necessity Case by Case

    Make medical necessity determinations on a case-by-case basis using the definition of medical necessity contained in the applicable Medicaid state contract, regulatory guidance, CMS requirements, or Medical Necessity Criteria Policy ADMIN.00004.

    Documentation Required

    Support Medical Necessity Review

    Support medical necessity review by submitting the request with the clinical information and documentation needed to apply the applicable criteria and make an informed determination.

    • Identify the service, setting, and requested level of care.
    • Provide relevant clinical documentation supporting the request.
    • Use the applicable InterQual, MCG, ASAM, Medical Policy, or Clinical UM Guideline requirements when applicable.
    Denial Risk

    Failure to Meet Established Criteria

    If a request does not meet established criteria guidelines, it will be referred to a licensed physician reviewer with the appropriate clinical expertise to make a decision.