Medical guidelines used to make coverage decisions.
InterQual Clinical Criteria
InterQual® evidence-based clinical decision support criteria used to make medical necessity determinations.
Drug policies assist in the administration of the pharmacy benefit.
A Health Plan policy that defines and outlines correct coding and payment guidelines.
Guidelines for credentialing to determine qualifications, career history, education, training, licensure and certifications.
Clinical Editing Policies
Guidelines for the review of submitted claims, for appropriate coding and reimbursement.
Substance Use & Alcohol Treatment
Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) clinical tool.