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Guidelines and criteria

To help provide our members with consistent, high-quality care that uses services and resources effectively, we’ve chosen certain clinical practice guidelines. 

We also use medical determination criteria to make decisions about medical necessity. This includes the care and services our members need for health.

Clinical practice guidelines

We’ve chosen certain clinical guidelines to:

  • Help our providers give our members consistent, high-quality care
  • Ensure good use of services and resources
  • Provide treatment protocols for specific conditions, as well as preventive health 

These guidelines clarify our standards and expectations. They should not:

  • Come before your responsibility to provide treatment based on the member’s needs
  • Substitute as orders for treatment of a member
  • Guarantee coverage or payment for the type or level of care a provider proposes

We have adopted these guidelines for:

Medical determination criteria

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:

  • Nationally recognized
  • Community-developed
  • Evidence-based
  • Accepted and reviewed based on our policies and procedures

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:

  • Criteria that state or federal regulatory agencies require
  • Applicable Milliman Care Guidelines (MCG) as the main decision support for most clinical diagnoses and conditions
  • Aetna Clinical Policy Bulletins (CPBs) 
  • Aetna Clinical Policy Council Review (when needed)

Check MCG criteria 

How to access Milliman Care Guidelines (MCG) clinical criteria (PDF)

Check CPB criteria 

How to access Aetna Clinical Policy Bulletins (CPBs) (PDF)

For outpatient and inpatient behavioral health care reviews, we use these criteria in this order:

  • Criteria that federal and state regulatory agencies require
  • Milliman Care Guidelines (MCG): Care management guidelines based on the latest research, scholarly articles and data analysis
  • American Society of Addiction Medicine (ASAM) CONTINUUM™ is an electronic assessment tool that allows clinicians to leverage a computerized clinical decision support system (CDSS). ASAM CONTINUUM™ guides interviewers through a whole-person comprehensive assessment aligned with the six dimensions of The ASAM Criteria to determine service planning, transfer recommendations, and produces a level of care recommendation for the least intensive, but safe and appropriate setting
  • The Child and Adolescent Level of Care Utilization System or CALOCUS is a standardized assessment tool that provides determination of the appropriate intensity of services needed by a child or adolescent and their family, and guides provision of ongoing service planning and treatment outcome monitoring in all clinical and community-based settings.  
  • The Level of Care Utilization System (LOCUS): A tool from the American Association of Community Psychiatrists — it allows staff who work with patients who have psychiatric problems in inpatient hospitals to decide the level of care a person should receive
  • Aetna Clinical Policy Bulletins (CPBs)
  • Aetna Clinical Policy Council Review (when needed)

Check MCG criteria 

How to access Milliman Care Guidelines (MCG) clinical criteria (PDF)

Check CPB criteria 

How to access Aetna Clinical Policy Bulletins (CPBs) (PDF)

Questions?

Check your provider manual for answers. Or contact us.