Clinical Care Criteria, Transition of Care

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Clinical Care Criteria

Community Health Plan uses Clinical Coverage Criteria and Milliman Care Guidelines as the basis for Care Management decisions. In circumstances where there are no Clinical Coverage Criteria or Milliman Care Guidelines applicable to a Care Management decision, CHP uses the definition of medical necessity applicable to the line of business. Consideration is also given to individual clinical circumstances and the capabilities of the local delivery system. Community Health Plan’s medical directors will take into consideration the enrollee's age, social situation, comorbidities, and availability of services within the community when making utilization review determinations.

Clinical Coverage Criteria are available here. Milliman Care Guidelines are available through the Care Management Portal at https://jiva.chpw.org. The definition of medical necessity is available in the Member Handbooks for each line of business. Community Health Plan will make this information available in hard copy or electronically upon request.

Transition of Care

From time to time, enrollee benefits may expire during a course of treatment through termination of the contract, disenrollment, or exhaustion of available benefits. The Care Management staff will work with enrollees to assist in transitioning to other care when necessary. They will make contact with community agencies or make referrals to public assistance as appropriate and authorized by the enrollee.