Clinical Coverage 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.

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.