Utilization Management Clinical Criteria

Welcome to the Utilization Management Clinical Criteria page. IEHP has created UM Subcommittee Approved Authorization Guidelines to serve as one of the sets of criteria for medical necessity decisions. Our goal in creating this page is to provide you with easily accessible electronic versions of IEHP’s UM guidelines. IEHP utilizes a variety of sources in developing our UM guidelines which include:

• Medicare and Medi-Cal’s coverage policy statements
• Evidence in the peer-reviewed published medical literature
• Technology assessments and structured evidence reviews
• Evidence-based consensus statements
• Expert opinions of healthcare Providers
• Evidence-based guidelines from nationally recognized professional healthcare organizations and public health agencies.

IEHP is also licensed to use MCG Guidelines, Apollo Medical Review Criteria, and InterQual to guide in utilization management decisions.

Since medical technology is constantly evolving, our clinical guidelines are subject to change without prior notification. Additional UM Subcommittee Guidelines may be developed as needed or may be withdrawn from use.

Please note that benefits may vary based on Member’s line of business; therefore, certain services discussed in the UM Subcommittee Guidelines may not be a covered benefit.

Providers may obtain information about criteria, either in general or relating to specific UM decisions, from IEHP upon request by contacting the IEHP UM Department. Please contact the IEHP Provider Relations Team at (909) 890-2054 to be connected to the UM Department.

In accordance to regulatory requirements from the Centers for Medicare and Medicaid Services (CMS), all Utilization Management Clinical Criteria are also accessible to the public at the external links listed below.

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.