Overview

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Medical Policies & Clinical UM Guidelines 
Welcome to the Amerigroup medical policy & clinical UM guideline website that provides access to electronic versions of medical policies and clinical UM guidelines.  
To view medical policies & clinical UM guidelines, click on the medical policy or UM guideline tab above. You can also use the “search” feature, which is housed in the top navigation, or click this link: Click Here to Search  
To determine which clinical UM guidelines have been adopted by your plan, or to determine if there are applicable third party criteria, please click on the appropriate state from the below list: 
Florida 
Georgia 
Iowa 
Kansas 
Maryland 
Tennessee 
Texas 
Dates associated with medical policies and clinical UM guidelines
Each medical policy and clinical UM guideline includes a Last Review Date and Publish Date. A medical policy or clinical UM guideline is made available on our public websites on its Publish Date. While the Publish Date is enterprise-wide, the actual implementation date may differ, depending on notification requirements. Local health plans will determine if new or revised medical policies and clinical UM guidelines require advance provider notification, based upon state laws, provider contracts and other considerations.  
Medical policy and clinical UM guidelines do not contain an implementation effective date which is the date that a health plan may begin using the new or updated medical policy or clinical UM guideline. The Implementation Date may be the same as the Publish Date when an updated document is an expansion of current criteria. When a new document or an update to an existing document that is more restrictive is published, the implementation date is determined by the local health plan since requirements regarding provider notification vary based upon state laws, provider contracts and other considerations.  
Third Party Criteria
In addition to the documents we develop and maintain for coverage decisions, we may adopt clinical utilization management criteria (UM guidelines) developed and maintained by third party organizations. Please click on the UM Guidelines tab above and choose ‘By Category’ for information on the guidelines available for use.  
Contact Us 
Please direct inquiries related to benefit coverage, new ID cards, billing practices, prior authorization, predetermination, reimbursement, medical policy or clinical guidelines to the local plan provider representative or Provider Relations by calling 1-800-454-3730. 
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