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, making benefit coverage determinations or coverage processes, EmblemHealth, GHI and HIP medical directors apply nationally recognized and accepted clinical criteria and guidelines.
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, EmblemHealth, GHI and HIP 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 are given an opportunity to augment the clinical information available to the medical director for consideration specific to their cases. 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 adverse determination.