Clinical Care Management Criteria

We use several resources to determine whether a specific intervention is medically necessary. Each case is assessed using appropriate criteria, also taking into account individual case information. 

We rely on the nationally recognized MCG Guidelines as the primary source for evidence-based recommendations for clinical coverage. In addition, we have created Clinical Coverage Criteria (CCCs) for situations not addressed by MCG Guidelines. For behavioral health medical necessity decisions we use Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) criteria, MCG criteria, and American Society of Addiction Medicine (ASAM) criteria for substance use disorders. You can refer to LOCUS/CALOCUS documents on the Provider  Forms and Tools page.

For Medicare members, CHPW utilizes the Centers for Medicare and Medicare Services (CMS) national coverage determinations (NCDs) and local coverage determinations (LCDs), if available. NCDs and LCDs are available through Noridian, Washington’s Medicare Fee-for-Service Contractor, or they are accessible on the CMS website. If CMS criteria are not available, then MCG Guidelines and/or CHPW's CCCs are used.

Our medical directors will take into consideration the enrollee's age, social situation, co-morbidities, and availability of services within the community when making utilization review determinations. These guidelines are available through the Care Management Portal.

Continuity and Transition of Care

From time to time, enrollee benefits may be transferred from one plan or primary care provider to another or expire during a course of treatment through termination of the contract, disenrollment, or exhaustion of available benefits. At times like these, we promote smooth and seamless continuity and transition of medically necessary care and integration of services. This way there is no interruption to the enrollee's care or prescription medications while striving to preserve the relationship between enrollees and providers throughout the process.

The Care Management staff will work with both enrollees directly or facilitating coordination efforts by providers to assist the continuity and transition to other care when necessary. They will contact community agencies or make referrals to public assistance as appropriate and authorized by the enrollee. They are also available to assist providers to coordinate appropriate services and programs available to enrollees from such resources as:

  • Care Managers
  • First Steps Maternity Support Services/Infant Case Management
  • Transportation and Interpreter Services
  • Patient Review and Coordination (PRC) program, for enrollees who meet the criteria identified in WAC 182-501-0135
  • Dental services
  • Foster Care/Fostering Well-Being
  • Health Homes
  • Regional Support Networks for mental health services
  • Substance Use Disorder services
  • Aging and Disability Services, including home and community based services
  • Skilled nursing facilities and community-based residential programs
  • Early Support for Infants and Toddlers (ESIT)
  • Department of Health and Local Health Jurisdiction services, including Title V services for Children with special health care needs


Click to see summary of latest updates to Clinical Coverage Criteria

Utilization/Medical Management