Clinical Practice Guidelines and Recommendations
- American Academy of Pediatrics (AAP)
Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis | Pediatrics | American Academy of Pediatrics (aap.org) - National Kidney Foundation (NKF)
KDOQI Guidelines/Commentaries - Centers for Disease Control and Prevention (CDC)
CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 | MMWR Centers for Disease Control and Prevention (CDC)
- American Psychological Association
APA Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts
American Psychiatric Association
Major depressive disorder: Validated treatments and future challenges - PMC (nih.gov) - American Diabetes Association (ADA)
Volume 47 Issue Supplement_1 | Diabetes Care | American Diabetes Association (diabetesjournals.org) American Academy of Pediatric Dentistry (AAPD)
- Substance Abuse and Mental Health Services Administration (SAMHSA)
Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants | SAMHSA Publications and Digital Products - American Society of Addiction Medicine (ASAM)
ASAM Clinical Guidelines
Medical Determination Criteria
Our clinical and medical management teams use national guidelines and resources when making medical determinations. The resources include, but are not limited to:
- CMS National Coverage Determination
- CMS Local Coverage Determination
- UptoDate
- Plan Developed Clinical Policies
- Behavioral Health Residential Facility Criteria – Adults and Children
- Adults Behavioral Health Therapeutic Homes
- Therapeutic Foster Care for Children
- Admission and Continued Stay Authorization Criteria for Behavioral Health Inpatient Facilities (BHIF) for persons under age 21/Residential Treatment Center
To obtain our national and state recognized medical necessity criteria applied to behavioral health and medical decisions, please contact us at 1-800-322-8670 (TTY: 711).
For more information about our care management programs, please call us at 1-800-322-8670 (TTY: 711).