Medical Policies and Clinical UM Guidelines

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Medical Policies  
Amerigroup has developed medical policies that serve as one of the sets of guidelines for coverage decisions. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the medical policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Medical policy does not constitute plan authorization, nor is it an explanation of benefits.  
Medical policies can be highly technical and complex and are provided here for informational purposes. The medical policies do not constitute medical advice or medical care. Treating health care professionals are solely responsible for diagnosis, treatment and medical advice. Amerigroup members should discuss the information in the medical policies with their treating health care professionals.  
Medical technology is constantly evolving and these medical policies are subject to change without notice, although Amerigroup will use good faith efforts to provide advance notice of changes that could have a negative impact on benefits. Additional medical policies may be developed from time to time and some may be withdrawn from use. The medical policies generally apply to all Amerigroup benefits plans, although some local variations may exist. Members should contact Member Services for specific coverage information.  
The doctors, hospitals and other providers which are part of the network of providers referred to in this document are independent contractors who exercise independent judgment and over whom Amerigroup has no control or right of control. They are not agents or employees of Amerigroup.  
If you would like to request a hard copy of an individual medical policy, please contact your local Provider Relations representative or Provider Relations at 1-800-454-3730. 
 
Clinical UM Guidelines  
Amerigroup has developed clinical UM guidelines that serve as one of the sets of guidelines for coverage decisions. Amerigroup is also licensed to use InterQualTM guidelines to guide utilization management decisions. This may include but is not limited to decisions involving precertification, inpatient review, level of care, discharge planning and retrospective review.  
The InterQualTM guidelines licensed include (1) LOC: Outpatient Rehabilitation & Chiropractic, (2) LOC: Home Care, (3) LOC: Subacute/SNF, (4) LOC: Rehabilitation, (5) LOC: Long-Term Acute Care, (6) LOC: Acute Pediatric, and (7) LOC: Acute Adult.  
Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the clinical UM guidelines. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. A clinical UM guideline does not constitute plan authorization, nor is it an explanation of benefits.  
Clinical UM guidelines can be highly technical and complex and are provided here for informational purposes. These guidelines do not constitute medical advice or medical care. Treating health care providers are solely responsible for diagnosis, treatment and medical advice. Amerigroup members should discuss the information in the clinical UM guideline with their treating health care providers.  
The clinical UM guidelines published on this website represent the clinical UM guidelines currently available to all health plans throughout our enterprise. These guidelines address the medical necessity of existing, generally accepted services, technologies and drugs. Because local practice patterns, claims systems and benefit designs vary, a local plan may choose whether to implement a particular clinical UM guideline. 
Medical technology is constantly evolving and clinical UM guidelines are subject to change without notice. Additional clinical UM guidelines may be developed from time to time and some may be withdrawn from use. Members should contact Member Services for specific coverage information. 
The doctors, hospitals and other providers which are part of the network of providers referred to in this document are independent contractors who exercise independent judgment and over whom Amerigroup has no control or right of control. They are not agents or employees of Amerigroup.  
If you would like to request a hard copy of an individual clinical UM guideline or InterQualTM guideline, please contact your local Provider Relations representative or Provider Relations at 1-800-454-3730. 
You may also click on the following link to view a list of the specific Clinical UM Guidelines adopted by Amerigroup:  
 
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