Guideline Overview
Blue Zones Health performs medical management functions in connection with the health plans it administers or supports. These activities may include review of medical necessity and appropriate level of care for covered services. Blue Zones Health determines medical necessity and appropriate level of care according to a hierarchy of criteria based on the applicable benefit plan package (Evidence of Coverage).
There are times when applicable statutes, regulations, National Coverage Determinations (NCDs), and Local Coverage Determinations (LCDs) do not fully establish the coverage criteria for an item or service. This occurs when:
- A. Additional, unspecified criteria are needed to interpret or supplement general provisions to determine medical necessity consistently;
- B. NCDs or LCDs include flexibility that explicitly allows for coverage in circumstances beyond the specific indications listed; or
- C. There is an absence of any applicable statutes, regulations, NCDs, or LCDs setting forth coverage criteria.
In these cases, Blue Zones Health may use coverage criteria developed or licensed by a health plan or by Blue Zones Health to determine medical necessity and/or appropriate level of care. Blue Zones Health uses MCG Care Guidelines or InterQual criteria when needed to fully establish coverage criteria for an item or service under review, because the clinical benefits of using such additional criteria — as described in and supported by the evidence detailed within each guideline — are highly likely to outweigh any clinical harms that may result from delayed or decreased access to the item or service.
MCG Care Instructions
MCG care guidelines are the intellectual property of MCG Health, and access is strictly controlled. Users may not distribute any MCG content without permission from MCG. By following these instructions, you will have access to view MCG care guidelines online.
Disclaimer
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