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.
Carelon Medical Benefits Management Guidelines
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.