Clinical Guidelines


Medicare Guidelines

https://www.cms.gov/medicare-coverage-database/search.aspx
https://med.noridianmedicare.com/web/medicare

Medi-Cal Guidelines

https://mcweb.apps.prd.cammis.medi-cal.ca.gov/publications/manual?q=&search

Health Plan Guidelines

https://www.healthnet.com/content/healthnet/en_us/providers/working-with-hn/medical_policies.html
https://medicalpolicy.scanhealthplan.com/
https://www.blueshieldca.com/en/provider/authorizations/policy-medical
https://www.molinahealthcare.com/providers/il/medicaid/resource/Molina-Medical-Coverage-Guidelines.aspx
https://www.uhcprovider.com/en/policies-protocols/clinical-guidelines.html
https://www.bndhmo.com/clinical-criteria
https://apps.humana.com/tad/tad_new/home.aspx?type=provider
Clinical Practice Guidelines (CPG) (caloptima.org)

Other Guidelines

https://www.ssa.gov/OP_Home/ssact/title19/1927.htm

MCG guidelines would only be used in the instance where there is no Medicare NCD or LCD/LCA or Health Plan policy addressing the requested service.

The clinical benefits of using this criteria are highly likely to outweigh any clinical harms, including from delayed or decreased access to services, because the criteria is unlikely to lead to circumstances where services are inappropriately denied.

MCG Guidelines

Conifer Health uses MCG Guidelines to help review medical necessity for health service requests. MCG Guidelines are the protected intellectual property of MCG. Conifer Health is not able to distribute them without the permission of MCG. MCG has provided a tool that allows Conifer Health members and prospective member to view relevant MCG guidelines, however you will not be able to print them.

Follow the instructions below for access

Step 1: Click here to access the MCG Guidelines, read the disclaimer and accept the terms and conditions.
Step 2: Complete the User Information Form
Step 3: Complete the Verification process to continue.
Step 4: Click on the arrow icon.
Step 5: Click on the guidelines you wish to review.
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