Commercially Produced Clinical Criteria Guidelines Used to
Determine Medical Necessity of Services for Claim Payment
Purposes.
Milliman Care Guidelines are used for the approval and current
review of all scheduled and emergency acute inpatient hospital
admissions. CMS guidelines are used for the approval and
current review of all skilled nursing facility and acute
rehabilitation admissions. Home Care and Home Infusion are
managed through our online benefits system with occasional
backup from the CMS site. All admission types are also subject
to Corporate Medical Policy
Internally Produced Clinical Guidelines Used to Determine
Medical Necessity of Services for Claim Payment Purposes
