In this section you will find current versions of Medica utilization management (UM) policies, coverage policies, Institute for Clinical Systems Improvement (ICSI) guidelines, and Medica clinical guidelines.

Documents are developed using an evidence-based approach analyzing scientific literature and input from practicing physicians, Care Management staff and Medica Medical Directors. Documents are updated as necessary.

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What's New

Information & Instructions
This section includes the Foreward to the Medical Policy Manual, Coverage Policies Background Information, and a form to submit comments or literature related to an existing policy.

Utilization Management Policies
A utilization management (UM) policy is a document containing clinical criteria used by Medica staff members for prior authorization, appropriateness of care determination and coverage. The criteria are specific to the clinical characteristics of the population that will benefit from the treatment or technology. The needs of individual patients who may not meet these criteria must be considered and are addressed by the process in the section labeled "Coverage Issues" on the UM policy.
 
Prior Authorization List

Coverage Policies
A coverage policy is a document that is developed to communicate decisions about coverage and benefits for various medical services.  Each coverage policy contains a description of the medical service, as well as the coverage determination, product application, coding considerations and requirements for prior authorization.

Inactivated Policies

ICSI Guidelines
An Institute for Clinical Systems Improvement (ICSI) guideline represents best practice for prevention and treatment of health conditions. These are intended to improve the effectiveness, efficiency and consistency of patient care, and provide a common foundation for clinical improvement initiatives.

Medica Clinical Guidelines
A Medica clinical guideline, adapted from regional or national credible sources, is used by physicians in the network as a reference guide to encourage quality care. Clinical guidelines are used internally at Medica to develop member education materials, disease management recommendations, and various quality studies. These guidelines are in addition to the guidelines that Medica has adopted from ICSI.

Index