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    Guidelines and criteria

    To help provide our members with consistent, high-quality care that uses services and resources effectively, we’ve chosen certain clinical practice guidelines. 

    We also use medical determination criteria to make decisions about medical necessity. This includes the care and services our members need for health.

    Clinical practice guidelines

    We’ve chosen certain clinical guidelines to:

    • Help our providers give our members consistent, high-quality care
    • Ensure good use of services and resources
    • Provide treatment protocols for specific conditions, as well as preventive health 

    These guidelines clarify our standards and expectations. They should not:

    • Come before your responsibility to provide treatment based on the member’s needs
    • Substitute as orders for treatment of a member
    • Guarantee coverage or payment for the type or level of care a provider proposes

    We have adopted these guidelines for:

    Need to learn more about the guidelines? Check the topics and links that follow.  

    If you’re a pediatrician or family medicine practitioner working with children:

    • Fully understand the Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program and periodicity schedule to help ensure children under age 18 get the screenings and preventive care they need
    • Be familiar with the childhood immunization schedule  

    As people age, we need to catch disease as early as possible. This helps ensure the best care, leading to the best results. Learn more about preventive and treatment guidelines for specific conditions in adults.

    Adult immunization schedule

    Remember — kids aren’t the only ones who need immunizations. Make sure adult members are up to date on their influenza, hepatitis A and B, measles, mumps and rubella (MMR) and other vaccines.

    Community-acquired pneumonia (CAP) clinical guideline

    The CAP clinical guideline helps us develop an integrated approach to the outpatient management of CAP with an emphasis on:

    • Prevention
    • Early detection 
    • Patient education

    See guidelines (PDF) from the Infectious Diseases Society of America and American Thoracic Society Consensus.

    HIV guidelines

    Check guidelines and resources from the National Institutes of Health.

    Preventive health care guidelines for adults

    1. Health maintenance exam by age and frequency
      • 18 to 25 years of age, every 5 years
      • 26 to 39 years of age, every 5 years
      • 40 to 49 years of age, every 3 years
      • 50 to 65 years of age, every 1 to 2 years
      • 65 years and older, every 1 to 2 years
    2. Cervical cancer screening
      • Every 1 to 3 years starting at age 18 or when sexually active. Frequency may decrease with no history of abnormal Pap tests and three or more tests are normal.
    3. Diabetes screening
      • Test at age 45 for adults with no symptoms and then every 3 years.

    Medical determination criteria

    We use certain criteria to make decisions about medical necessity — what care and services our members need for health. We apply the criteria based on member needs and local resources. The staff who make decisions receive training on the criteria.

    The criteria are:

    • Nationally recognized
    • Community-developed
    • Evidence-based
    • Accepted and reviewed based on our policies and procedures

    The right people help create, adopt or review the criteria every year. They also make sure the criteria are right for our members’ needs. When national or community-based clinical practice guidelines receive updates, we make updates as well.

    We apply the criteria consistently and think about the needs of members. And we consult with requesting providers when it’s the right thing to do.

    For prior authorization requests for outpatient services and inpatient medical care, we use these criteria:

    • Criteria that state or federal regulatory agencies require
    • Applicable Milliman Care Guidelines (MCG) as the main decision support for most clinical diagnoses and conditions
    • Aetna Clinical Policy Bulletins (CPBs) 
    • Aetna Clinical Policy Council Review (when needed)

    Check MCG criteria 

    How to access Milliman Care Guidelines (MCG) clinical criteria (PDF)

    Check CPB criteria 

    How to access Aetna Clinical Policy Bulletins (CPBs) (PDF)

    For outpatient and inpatient behavioral health care reviews, we use these criteria in this order:

    • Criteria that federal and state regulatory agencies require
    • Milliman Care Guidelines (MCG): Care management guidelines based on the latest research, scholarly articles and data analysis
    • American Society of Addiction Medicine (ASAM) PPC-2R: Guidelines about the right type of care and the level of care intensity for people with substance use disorders
    • The Child and Adolescent Service Intensity Instrument (CASII): Standardized tool that finds the right level of service intensity for children, youth and families need
    • The Level of Care Utilization System (LOCUS): A tool from the American Association of Community Psychiatrists — it allows staff who work with patients who have psychiatric problems in inpatient hospitals to decide the level of care a person should receive
    • Aetna Clinical Policy Bulletins (CPBs)
    • Aetna Clinical Policy Council Review (when needed)

    Check MCG criteria 

    How to access Milliman Care Guidelines (MCG) clinical criteria (PDF)

    Check CPB criteria 

    How to access Aetna Clinical Policy Bulletins (CPBs) (PDF)

    Questions?

    Check your provider manual for answers. Or contact us.