Medical Policies and Clinical UM Guidelines
Medical policies are used by all plans and lines of business unless Federal or State law — as well as contract language, including definitions and specific contract provisions or exclusions — take precedence over a medical policy. Those provisions will be considered first in determining eligibility for coverage before the medical policy is used to determine medical necessity.
Clinical UM Guidelines
The Clinical Utilization Management (UM) Guidelines published on this website are not always used by all plans or lines of business. Clinical UM Guidelines are available for adoption to review the medical necessity of services related to the guideline when the Plan performs a utilization review for the subject. Because practice patterns, claims systems and benefit designs vary, a local plan may choose whether to adopt a particular clinical UM guideline.
Health plans or lines of business which determine there is not a need to adopt a clinical utilization management guideline may instead use the guideline for educational purposes or to review the medical necessity of services for any provider who has been notified that his or her claims will be reviewed due to billing practices or claims that are inconsistent with other providers.
To determine which clinical utilization management guidelines have been adopted by your plan, or to determine if there are other applicable criteria, use the guideline adoption link provided here:
MCG Care Guidelines are licensed and utilized to guide utilization management decisions for some health plans. This may include but is not limited to decisions involving prior authorization, inpatient review, level of care, discharge planning and retrospective review. MCG guidelines licensed include:
- Inpatient and Surgical Care
- General Recovery Care
- Recovery Facility Care
- Chronic Care
Customizations to MCG Care Guidelines
This document provides a summary of customizations to the MCG Care Guidelines 24th Edition (Publish date January 20, 2021).
Customizations to MCG Care Guidelines 24th Edition
This document provides a summary of customizations to the MCG Care Guidelines 25th Edition (Publish date June 25, 2021).
Customizations to MCG Care Guidelines 25th Edition
AIM Specialty Health (AIM)*
Our health plans may use guidelines developed by AIM to perform utilization management services for some procedures and certain members.
AIM guidelines applicable to Plan programs are maintained by AIM. Updates to these guidelines can be found on their website.
All pharmacy services are carved out to MO HealthNet except for medications billed as part of an inpatient admission.
* AIM Specialty Health is an independent company providing some utilization review services on behalf of Healthy Blue.
* MCG is an independent company providing utilization review guidelines on behalf of Healthy Blue.
- Publish date: the date a medical policy or clinical UM guideline was made available on our public websites. Note that while a publish date is enterprise-wide, the implementation date may differ depending on notification requirements. Please refer to the plan Provider Newsletter for more information relating to implementation dates.
- Last review date — the date a medical policy or clinical UM guideline was reviewed and approved
If a medical policy or clinical UM guideline is not yet implemented for your Plan, historical versions may be accessed.
To see a list of all Medical Policies and Clinical UM Guidelines, visit our Full List page.