Welcome to Your Medicare Advantage Clinical Criteria Portal

Your Resource for Authorization Guidelines

As a valued Medicare Advantage member, we understand the importance of accessing clear and comprehensive information regarding clinical criteria for authorizations. Our portal is designed to provide you with everything you need to navigate your health plans authorization process with ease.

Why Use Our Clinical Portal?

 

Transparency: Understand the criteria used to evaluate and approve your healthcare services.

Convenience: Access detailed guidelines and requirements for authorizations from the comfort of your home specific to your health plan.

Support: Find answers to your questions and get assistance when you need it.

Key Features

Search Clinical Criteria for Your Health Plan:

  • Easily search for specific clinical criteria by service type, treatment, or condition within your health plan’s guidelines.
  • Comprehensive guidelines for a wide range of medical procedures and treatments.

Authorization Requirements:

  • Detailed explanations of the documentation and steps required for authorization.
  • Specific criteria for approvals to help ensure you meet all necessary conditions.

Policy

Evidence based; nationally accepted criteria are utilized when authorizing services. In addition, the members’ needs: age, co-morbidity, complications, home     environment, treatment progress and psychosocial situation are also taken into consideration. Application of the criteria shall be based on the needs of individual patients and characteristics of the local delivery system. The criteria utilized is focused on both the inpatient and outpatient services requested.

Procedure

  1. The senior Physician shall oversee the application of the criteria will depend upon the member’s age, co-morbidities, and progress in treatment, psychosocial situation, home environment, network resources and support system. The decision-making for UM is based only on appropriateness of care and service and existence of coverage. UM decision-making criteria that are objective and based on current medical evidence.

    Applying criteria based on availability of outpatient services in lieu of inpatient services such as ambulatory surgical centers vs. inpatient surgery. Applying criteria based on availability of highly specialized services, such as transplant facilities or cancer centers. Applying criteria based on Availability of skilled nursing facilities, subacute care facilities or home care in the organization’s service area to support the patient after hospital discharge. Apply criteria based on Local hospitals’ ability to provide all recommended services within the estimated length of stay. The criteria or guidelines must be consistent with sound clinical principles and processes and must be evaluated at least annually and updated as necessary. IPA may develop for use proprietary criterion; such criterion requires prior approval from Health Plans Medical Policy Committee prior to use for UM decision-making.

  1. Appropriate licensed practitioners are involved in developing, adopting, and reviewing criteria. Reviewed on an annual basis or as needed.
  2. The use and application of appropriate criteria and all criteria is documented in EZCAP for all UM decisions.
  3. ECHO Criteria resources include Medi-Cal Guidelines, Medicare Guidelines (CMS) NCD, LCD, MCG Guidelines, Clinical Practice Guidelines and Health Plan guidelines.
  4. Hierarchy of Criteria:
    a.   ECHO clinical staff shall apply criteria in the following hierarchy (Medicare):
          i.   Medicare National Coverare Determination (NCD)
         ii.   Medicare Local Coverage Determination (LCD)
        iii.   Medicare Claims Processing Manual
        iv.   CMS Benefit Policy Manual/Medicare Managed Care Manual
         v.   Health Plan Guidelines or Evidence of Coverage
        vi.   MCG Care Guidelines
       vii.   Medicare Program Integrity Manual
    b.   Consideration of the CMS-approved EOB, formulary, appropriate CMS regulations and guidance, required drug compendia, previous claims history, and all submitted clinical information. Making and documenting requests for necessary clinical documentation from providers and prescribers when documentation is needed to properly adjudicate coverage/organization determination requests and appeals. (42 C.F.R. §§ 422.566(a) and (d), 423.562(a) and (d))

    c.   Mental health and Substance Use Disorders MH/SUD American
         i.   Society of addiction Medicine (ASAM) Criteria
        ii.   Level of care utilization system (LOCUS) guidelines
       iii.   Child and Adolescent Level of Care Utilizations (CALOCUS) Guidelines
       iv.   Early childhood service intensity instrument (ECSII) Guidelines

    d.   ECHO clinical staff shall apply criteria in the following hierarchy (DSNP)
        i.   Medicare:
       ii.   CMS National Coverage Determination (NCD)
      iii.   CMS Local Coverage Determination (LCD)
      iv.   CMS Benefit Policy Manual/Medicare Managed Care Manual
       v.   MCG Guidlines
      vi.   Medi-Cal:
     vii.   Medi-Cal Guidelines
    viii.   MCG Guidelines
      ix.   Health Plan Evidence of Coverage (EOC)

Stay Informed and Empowered

 

We are committed to providing you with the resources and support you need to manage your healthcare effectively. Stay informed about your benefits and take charge of your health with confidence.

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1-888-975-3246

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Thank you for being a valued Medicare Advantage member. We are here to support you every step of the way.