Utilization Management Clinical Criteria Hierarchy

‎ ‎ ‎ ‎ ‎ •‎ ‎ Plan Eligibility and Benefit Coverage 

‎ ‎ ‎ ‎ ‎ •‎ ‎ Federal or State Guidelines, where applicable. Then the following hierarchy will be followed:  

‎ ‎ ‎ ‎ ‎ •‎ ‎ For Medi-Cal: DHCS criteria is the primary source, Health Plan criteria is secondary source and then evidence based criteria [such as MCG and Apollo Medical Review Criteria Guidelines for Managed Care]. 

‎ ‎ ‎ ‎ ‎ •‎ ‎ For Commercial: DMHC - Knox Keene Act - Title 28 is the Primary Source, Health Plan criteria is secondary source with evidence based criteria [such as MCG and Apollo Medical Review Criteria Guidelines for Managed Care] as next source. 

‎ ‎ ‎ ‎ ‎ •‎ ‎ For Medicare Advantage: CMS is the Primary Source with hierarchy being National Coverage Determinations [NCD] then Local Coverage Determinations [LCD], Local Coverage Articles [LCA], Medicare Manuals [Medicare Managed Care, Medicare Benefit Policy, Medicare Program Integrity, Medicare Claims Processing], then Health Plan criteria and then evidence based [such as MCG and Apollo Medical Review Criteria Guidelines for Managed Care] as next source. 

‎ ‎ ‎ ‎ ‎ •‎ ‎ World Professional Association for Transgender Health [WPATH]: Standards of Care for the Health of Transsexual, Transgender and Gender nonconforming people from WPATH will be utilized as primary source to provide clinical guidance in determination of coverage .  DHCS criteria is primary source, Health Plan criteria is secondary source and then evidence based [such as MCG and Apollo Medical Review Criteria Guidelines for Managed Care] as next source. 

A copy of the criteria used to make a determination is available upon request.

Additional Resources:

California Code of Regulations, Title 22 

www.dhcs.ca.gov/services/adp/Pages/CA_Code_Regulations.shtml.aspx

DHCS All-Plan Letters and Other DHCS Regulatory Guidance regarding UM 

www.dhcs.ca.gov/formsandpubs/Pages/AllPlanLetters.aspx

DMHC Regulatory Guidance regarding UM 

https://www.dmhc.ca.gov/LawsRegulations.aspx

Medicare Benefit Manual

https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c01.pdf

Centers for Medicare and Medicaid Services (CMS) Guidelines National Coverage Determinations (NCD)  

https://www.cms.gov/medicare-coverage-database/reports/national-coverage-ncd-report.aspx?chapter=all&sortBy=title

Local Coverage Determinations (LCD)  

https://www.cms.gov/medicare-coverage-database/reports/local-coverage-final-lcds-alphabetical-report.aspx?lcdStatus=all

Local Coverage Articles

https://localcoverage.cms.gov/mcd_archive/reports/reports.aspx

Traditional Medicare Benefits

https://www.medicare.gov/Pubs/pdf/10116-your-medicare-benefits.pdf

World Professional Associate for Transgender Health (WPATH)  

www.wpath.org/publications/soc

Health Plan & MCG Guidelines

Alignment

Anthem Blue Cross (Elevance Health)

https://www.anthem.com/provider/policies/clinical-guidelines/

Blue Shield 

https://blueshieldofca.access.mcg.com/index

Brand New Day

https://www.bndhmo.com/clinical-criteria

https://brighthealth.access.mcg.com/index

Clever Care

Humana

www.humana.com/coveragepolicies

https://humanabh.access.mcg.com/index

LA Care

Molina

https://www.molinaclinicalpolicy.com/

https://molinahealth.access.mcg.com/index

Wellcare

https://www.wellcare.com/california/providers/clinical-guidelines

Apollo Managed Care

https://ehp.apollomanagedcare.com

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Rheumatoid Arthritis Support Network (RASN)

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California Advance Health Care Directive

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