Phccalifornia Coverage Criteria
Latest Phccalifornia coverage criteria updates13
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-14Services Reviewed Using InterQual CriteriaIdentifies medical, behavioral health, rehabilitation, durable medical equipment, home care, imaging, long-term acute care, procedural, and specialty pharmacy services that may be reviewed for medical necessity using InterQual criteria when Medi-Cal coverage criteria are not fully established; member eligibility and benefit limitations apply.All phccalifornia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-01-01Services Reviewed Using InterQual CriteriaThis policy identifies medical, behavioral health, rehabilitation, durable medical equipment, imaging, procedures, specialty pharmacy, and post-acute services that the Health Plan may review for medical necessity using InterQual criteria when Medicare coverage criteria are not fully established. Coverage remains subject to member eligibility, benefit limits, and applicable authorization processes.All phccalifornia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2017-12-31PHC-CA Clinical Criteria and GuidelinesThis 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.All phccalifornia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2009-10-06PHC-CA Transportation BenefitGoverns emergency medical, non-emergency medical, and non-medical transportation benefits, including coverage, authorization, documentation, booking, reimbursement, and oversight for eligible PHC California enrollees.All phccalifornia updates
- Coverage CriteriaClinical/Medical PolicyAcupunctureThis guideline governs when acupuncture is medically necessary, not medically necessary, or potentially eligible for coverage for members whose target condition meets specified clinical criteria.All phccalifornia updates
- Coverage CriteriaClinical/Medical PolicyClinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline ExistsGuides medical necessity and benefit determinations for services and related claims when no directly applicable Clinical UM Guideline exists, including services associated with providers on pre-payment review.All phccalifornia updates
- Coverage CriteriaClinical/Medical PolicyLiver TransplantationThis policy governs medical necessity and coverage criteria for whole or partial liver transplantation using deceased or living donors for individuals with end-stage liver disease due to irreversible liver damage. It also addresses liver retransplantation, contraindications, investigational services, and applicable transplant procedure coding.All phccalifornia updates
- Coverage CriteriaClinical/Medical PolicyOutpatient CystourethroscopyThis policy governs when outpatient cystourethroscopy is medically necessary for diagnostic, therapeutic, and urinary tract management indications for PHC California members.All phccalifornia updates
- Coverage CriteriaClinical/Medical PolicyOutpatient CystourethroscopyThis guideline governs when outpatient cystourethroscopy is medically necessary for diagnostic and therapeutic urologic indications. It applies to providers evaluating or requesting outpatient cystourethroscopy and related procedures.All phccalifornia updates
- Coverage CriteriaClinical/Medical PolicyPHC-CA COVID-19 TherapeuticsGoverns access to COVID-19 vaccinations and medically necessary COVID-19 therapeutics for PHC California enrollees, including provider evaluation, prescribing, pharmacy access, prior authorization, and case management support.All phccalifornia updates
- Coverage CriteriaClinical/Medical PolicyPHC-CA Utilization Management of Transitional Rent Community SupportThis policy governs how PHC California determines enrollee eligibility, authorizes, monitors, and discontinues Transitional Rent Community Support, including housing support plans, authorization timeframes, Room and Board limits, and county behavioral health coordination.All phccalifornia updates
- Coverage CriteriaClinical/Medical PolicyPHP Clinical Criteria and GuidelinesGoverns 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.All phccalifornia updates
- Coverage CriteriaClinical/Medical PolicySmall Bowel, Small Bowel/Liver and Multivisceral TransplantationThis policy governs medical necessity for isolated small bowel, combined small bowel/liver, multivisceral, living-donor, deceased-donor, and retransplantation procedures in adults and children. Coverage depends primarily on irreversible intestinal failure or short bowel syndrome, failure of total parenteral nutrition, transplant selection criteria, and absence of contraindications.All phccalifornia updates
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Tool Description
Search Phccalifornia coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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