In this section you will find current versions of Medica utilization management (UM) policies. 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.
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.
For medical services that require prior authorization, specified in the following UM policies as necessary, providers can refer to additional details on the Medica prior authorization process. To open and print Portable Document Format (.pdf) files you will need the computer application Adobe Acrobat Reader. If you don't have Acrobat Reader, you can download it by visiting http://www.adobe.com.
Important information – please read the Medical Policy Usage Notice before using these policies:Medical Policy Usage Notice