Clinical Review Criteria

Clinical review criteria will minimally meet the following requirements:

Authorization coverage decisions are based on the following:

MaineCare rules as outlined in the MaineCare Benefits Manual
Nationally recognized, evidence-based criteria that are applied on the basis of medical necessity and appropriateness of the requested service
The individual member’s circumstances

Clinical review criteria will meet nationally recognized standards of quality medical care and services.

Criteria are consistent with the provision of care at the appropriate:

Level of care
Time
Setting
Provider

Criteria will also be consistent with an efficient and effective utilization of resources available to recipients.

Clinical review criteria will take into consideration the individual circumstances of health care need and be used to administer and manage health care benefits and services based on medical need and presenting symptoms.

Prior to being used to support utilization decisions, clinical review criteria are reviewed by applicable medical directors and health professionals and approved for use by the Corporate Quality Management / Utilization Management Committee and the Quality Management Oversight committee. Criteria are reviewed annually, updated as necessary to reflect current medical standards and shall be made available upon a practitioner's or member’s written request.