Clinical Practice Guidelines

The organization follows: CMS guidelines to include National Coverage Determinations (NCD) and Local Coverage Determinations (LCD); Health Plan partner Clinical Guidelines (depending on the LOB) for any medical necessity determinations or, if none applicable, will use MCG or Apollo Clinical Guidelines to support benefit determinations. These guidelines are based on appropriateness and medical necessity standards. Each guideline is current and has references from the peer-reviewed medical literature, and other authoritative resources such as CMS Medicare.

For any medical necessity Denial or Recommendation of Denial, the Medical Director shall attempt to contact the requesting provider for peer-to-peer consultation. Applied Clinical Guidelines are available in both electronic and hard copy format. If a provider would like a copy of the guidelines, they may contact their assigned Provider Relations Representative and a copy will be provided. You may also access them with the following links:

For Health Plan specific guidelines, please refer to the member's health plan website.