Clinical review
We coordinate health care for our members to ensure they receive quality, timely and clinically appropriate care.
We or one of our delegated vendors will administer utilization management review and care management services. Except in the case of an emergency medical condition, we’ll provide prior authorization for services if required by the member’s benefit plan, including hospital inpatient stays or confinement.
You should become familiar with and follow our program requirements. We may require you to provide medical records and other information, including access to electronic health records.
Review our prior authorization requirements.
We base utilization-related decisions on our members’ clinical needs, benefit plans and 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:
Centers for Medicare & Medicaid Services’ Medicare Benefit Policy Manual
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