A structured framework for complex utilization management decisions.
Our physicians integrate applicable regulatory requirements, coverage policies, recognized decision-support criteria and patient-specific clinical judgment.
The right standard depends on the case
Coverage framework, payer, jurisdiction, service type, contract and clinical circumstances can all affect which resources are controlling or relevant.
Licensed Clinical Decision-Support Criteria
Structured clinical decision support for medical necessity, level of care and continued stay.
Used when authorized by the client programAuthorized Clinical Review Criteria
Evidence-based criteria used by many organizations for level-of-care and service review.
Used when authorized by the client programNCD & LCD
CMS national and Medicare Administrative Contractor local coverage determinations.
Explore NCD/LCD →Two-Midnight Framework
CMS hospital admission principles relevant to Medicare Part A patient-status review.
Explore Two-Midnight →Procedure Status / IPO
Current CMS procedure-status requirements incorporated into procedural admission review.
Explore procedure status →Health Plan Policies
Client-specific coverage requirements for procedures, tests, therapies and technologies.
Explore plan policies →Specialty Guidelines
Authoritative society guidance and clinical evidence for specialized questions.
Explore specialty guidance →Medical Necessity Process
See how we combine coverage framework, criteria, evidence and individual clinical circumstances.
View our process →Need physician review capacity?
Discuss ongoing coverage, overflow reviews, appeals, or a customized UM program.