Utilization Management Guidelines

Medical Necessity (UM) Review

The Clinical Services Program (CS Program) defines the process for the evaluation and monitoring of treatment/services provided to members by contracted practitioners. Medical necessity verification decisions are evaluated against established clinical guidelines supported by credible scientific evidence that meets industry standard research quality criteria and is adopted by an American Specialty Health clinical peer review committee. The CS Program defines the process for peer review evaluation of the appropriateness and effectiveness of submitted treatment/services including visits, examinations, diagnostic tests, diagnostic procedures, and therapeutic procedures.

State mandates, regulatory requirements, accreditation standards, or specific health plan delegation agreements may require modification of some sections of the CS Program for compliance. Where this occurs, the CS Program is modified and approved as applicable.

ASH’s clinical peer review committees have approved Clinical Practice Guidelines (CPGs) related to specific techniques, procedures, and technologies. These are available at Technique/Procedure Clinical Practice Guidelines .

Techniques or procedures identified by peer review committees as scientifically implausible or that pose a significant health and safety risk require obtaining specific informed consent from the patient. The informed consent should be signed prior to performing the technique or procedure and include, at a minimum, attestation that the patient understands what is known (evidence) and unknown (lack of evidence) about the technique or procedure, the possible risks associated with the technique or procedure, and other established evaluation or treatment options. A list of the techniques/procedures that have been specifically evaluated by ASHA clinical committees and the applicable Clinical Practice Guidelines are available at  Techniques and Procedures Not Widely Supported As Evidence-Based .

The policy defining the process by which Clinical Practice Guidelines are established and the definitions used by ASH clinical and peer review committees is available at  Evidence Based Health Information Evaluation / Technology Assessment and Evidence Selection and Evaluation .

TEXAS PROVIDERS ONLY - The Texas Standard Prior Authorization Request Form is available for those providers seeking prior authorization.