Welcome

In accordance with CMS Final Rule requirements, UHP provides public access to the clinical criteria used in our Utilization Management (UM) decision-making processes. When Medicare guidelines (e.g., NCDs, LCDs, Medicare Manuals) are not available or applicable, we utilize InterQual Criteria Access Management Co., LLC.

Our organization has access to the following InterQual criteria clinical subsets, which support evidence-based review decisions across a wide range of services and populations:

InterQual® Criteria Subsets Utilized:

• Acute Adult Criteria Clinical
• Acute Pediatric Criteria Clinical
• Adult and Geriatric Psychiatry
• Behavioral Health Services
• Inpatient Rehabilitation
• Long-Term Acute Care Criteria Clinical
• Procedures Criteria Clinical
• Subacute & SNF Criteria Clinical
• Substance Use Disorders
• Medicare Behavioral Health Navigator Clinical
• Medicare Imaging Navigator Clinical
• Medicare Post Acute & Durable Medical
• Medicare Procedures Navigator Clinical

Additional Clinical Reference Tools:

• AMA CPT® Codes IQ (Third Party License)
• NCCN® Drugs & Biologics Compendium

To view the InterQual® criteria applicable to your care, please click the link below: https://prod.ds.interqual.com/service/connect/transparency?tid=ac09c529-7150-4340-b7ad-0a57a050e17b

Any issues with InterQual link please contact: Product Support Phone number: 800-274-8374 (CRITERIA)

UM-022 InterQual® Clinical Criteria

Ultimate Health Plan will first use Medicare criteria (NCDs, LCDs, Medicare Manuals) and InterQual® criteria to make medical necessity determinations. When no established criteria exist, UHP will use internally adopted criteria informed by external authoritative sources such as the FDA, NIH, ACR, and NCCN.

• FDA- https://www.fda.gov/drugs
• NIH- https://www.nih.gov/health-information
• ACR- https://www.acr.org/Clinical-Resources
• NCCN- https://www.nccn.org/global/what-we-do/clinical-guidelines-translations

UM-037 Medical Necessity Determinations in the Absence of Established Clinical Criteria

Ultimate Health Plans delegates medical necessity utilization management decisions for vision, dental, and mental health/substance abuse services. The following delegated partners medical necessity criteria are accessible through the links below.

Behavioral Health Partner: Carelon

https://www.carelonbehavioralhealth.com/providers/resources/medical-necessity-criteria

Eye Care Partner: Premier Eye Care

https://www.premiereyecare.net/resources/

Dental Partner: FCL Dental

https://www.fcldental.com/members