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Clinical guidelines and policy bulletins


We’ve chosen certain clinical guidelines to help our providers get members high-quality, consistent care that uses services and resources effectively. These include treatment protocols for specific conditions, as well as preventive health measures.


These guidelines are intended to clarify standards and expectations. They should not: 


  • Take precedence over your responsibility to provide treatment based on the member’s individual needs
  • Substitute as orders for treatment of a member
  • Guarantee coverage or payment for the type or level of care proposed or provided

Medically necessary criteria

We use the following medical review criteria to make medically necessary decisions:


  • Criteria required by applicable state or federal regulatory agency
  • Medicaid pharmacy guidelines
  • MCG
  • American Society of Addiction Medicine (ASAM)
  • Level of Care Utilization System (LOCUS)
  • Children and Adolescent Service Intensity Instrument (CASII)
  • Child and Adolescent Needs Strengths Scale (CANS)[MJ1] [UC2] [UC3] 
  • Clinical policy bulletins (CPB)
  • Early Childhood Service Intensity Instrument (ECSII)


Also of interest: