Medicare Clinical Review Guidelines

HealthSpring uses Medicare guidelines and internal medical policies to help you get health care you need.

HealthSpring or one of our delegated vendors will administer utilization managementUtilization Management is the process in which we review requests (prior authorization) to ensure you are getting the right care at the right time, and limiting unnecessary costs. review and care management services. Except in the case of an emergency medical condition, we’ll provide prior authorization for those services if required by the member’s benefit plan, including hospital inpatient stays or confinement.

We base utilization-related decisions on your specific clinical and health care needs, benefit plans and the appropriateness of care employing well-established clinical decision-making tools. We also consider current evidence in widely used treatment guidelines and clinical literature, taking into account information provided by the provider or member. Criteria we may consider during the clinical review process include:

• CMS Medicare Benefit Policy Manual

• Centers for Medicare & Medicaid Services’ National Coverage Determinations

• CMS Local Coverage Determinations

• MCG Care Guidelines

• American Society of Addiction Medicine Clinical Guidelines

• HealthSpring Medical Policies

• EviCore Clinical Guidelines

• American Specialty Health Medical Coverage Policies

• WellMed® Medical Coverage Policies

• Member Evidence of Coverage

You should always talk to your provider about any specific health questions or concerns. You can also check with them if you have questions about prior authorization or medical policies.

If you want to know more about the utilization management process or how decisions are made about your care, Contact Us.