Medical Policies & Clinical UM Guidelines
Medical Policies address the medical necessity of new services or procedures and new applications of existing services or procedures. Clinical UM guidelines focus on detailed selection criteria, goal length of stay, and location for generally accepted technologies or services.
We routinely update our Medical Policies and Clinical UM Guidelines as part of the review process.
View the full list of MCG Care Guidelines.
Carelon Medical Benefits Management, Inc.
Our health plans may use guidelines developed by Carelon Medical Benefits Management, Inc. Guidelines to perform utilization management services for some procedures and certain members.
Carelon Medical Benefits Management guidelines applicable to Anthem Blue Cross and Blue Shield Medicaid (Anthem) programs are maintained by Carelon Insights. Updates to these guidelines can be found on their website.
CarelonRx, Inc.
CarelonRx is an independent company providing pharmacy benefit management services. The pharmacy Clinical Criteria for injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit are available for certain Medicare/Medicaid markets.
Related resources
- Clinical Utilization Management Criteria May 2023
- Clinical Utilization Management Criteria February 2023
- November 2022 Clinical Utilization Management Guidelines
- August 2022 Clinical Utilization Management Guidelines
- November 2021 Clinical Utilization Management (UM) Guidelines
- August 2021 Clinical Utilization Management (UM) Guidelines
- May 2021 Clinical Utilization Management (UM) Guidelines
- 2023 Clinical Practice Guidelines
- November 2020 Clinical Utilization Management (UM) Guidelines
- Preventive Health Guidelines
- Associates Performing Utilization Reviews
- Clinical Criteria for Utilization Management Decisions - Core Process
- Clinical Information for Utilization Management Reviews - Core Process
- Concurrent Review (Telephonic and On-site) and On-site Review Protocol Process - Core Process
- Emergency Services - Core Process
- Health Care Management Denial - Core Process
- Member Appeals and Provider Medical Necessity/Administrative denial appeals
- Prohibiting the Use of Financial Incentives When Making Medical Necessity Determinations – Core Process
- Subcontract UM Delegation
- Post-Service Review (Retrospective Review) Policy
- Transplant Approval Policy – Solid Organ/BMT/Stem Cell
- Use of Board Certified Consultants Medical Behavioral Health
- Utilization Management - Medicaid Delegation and Oversight
- Utilization Management Clinicians Responsibilities