Medical Clinical Policies
Medical clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures. Medical clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.
Not all policies found in the Maryland Physicians Care Medical Clinical Policy Manual apply to all Maryland Physicians Care members. Maryland Physicians Care policies are applied according to member eligibility and medical necessity criteria as defined in policy CP.MP.68. Policies in the Maryland Physicians Care Medical Clinical Policy Manual may have either a Maryland Physicians Care or a “Centene” heading. Maryland Physicians Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Maryland Physicians Care medical clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Maryland Physicians Care. In addition, Maryland Physicians Care may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Medical Clinical Policy Manuals or InterQual® criteria is payable by Maryland Physicians Care.
If you have any questions regarding these policies, please contact Customer Service and ask to be directed to the Medical Management department.