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Utilization Review Criteria Update

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Utilization Review Criteria Update

Utilization review criteria cover a broad range of common conditions, but cannot address every clinical situation. Most requests for treatment meet clinical criteria, follow guidelines and are approved quickly. If a request does not meet established criteria or guideline standards, the case is referred to a Medical Director.

When conducting clinical reviews or making benefit coverage determinations or coverage processes, our medical directors apply nationally recognized and accepted clinical criteria, guidelines and required procedures. We use InterQual Criteria, Apollo Managed Care Guidelines (edited by Margaret Bischel, MD), local and regional Medicare Coverage Guidelines, and other nationally recognized clinical guidelines. Each year, we review and update the Medical Policy criteria used to make clinical determinations. These guidelines are then reviewed and approved by our Medical Policy Committee, which is overseen by the Quality Improvement Committee.

Network clinicians have the opportunity to augment the clinical information provided with their request for consideration by the medical director. The criteria and guidelines used in a determination are available for review. Any request for copies of the criteria or guidelines should be made to the medical director who issued the determination.

If you have questions, sign in to emblemhealth.com to access our Message Center. Select "General Information" as the category in the drop-down menu on the "Ask a Question" page. Or you may speak to a customer service representative. A complete listing of telephone numbers is available in our Provider Manual. You may also review and download our Clinical Practice Guidelines.


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