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We’ve chosen certain clinical guidelines to:
These guidelines clarify our standards and expectations. They should not:
We have adopted these guidelines for:
We use certain criteria to make decisions about medical necessity — what care and services our members need for health. We apply the criteria based on member needs and local resources. The staff who make decisions receive training on the criteria.
The criteria are:
The right people help create, adopt or review the criteria every year. They also make sure the criteria are right for our members’ needs. When national or community-based clinical practice guidelines receive updates, we make updates as well.
We apply the criteria consistently and think about the needs of members. And we consult with requesting providers when it’s the right thing to do.
For prior authorization requests for outpatient services and inpatient medical care, we use these criteria:
Check MCG criteria
How to access Milliman Care Guidelines (MCG) clinical criteria (PDF)
Check CPB criteria
For outpatient and inpatient behavioral health care reviews, we use these criteria in this order:
Check MCG criteria
How to access Milliman Care Guidelines (MCG) clinical criteria (PDF)
Check CPB criteria
Check your provider manual for answers. Or contact us.
Another group or vendor provides the info on the next page. If you don’t want to leave our site, choose the “X” in the upper right corner to close this message. Or choose “Go on” to move forward.