Medical Review Criteria for Managing Care

Medical Review Criteria for Managing Care


  • The bible for health plan benefit interpretation guidelines.
  • More than 2,000 detailed clinical review criteria guidelines and evidence-based benefit interpretations.
  • Provides utilization management and claims departments with essential information to assist in medically-necessary benefit determinations.
  • Includes specific indications for medically necessary ambulatory care or inpatient tests and procedures.
  • Extensive literature references and other authoritative resources in each guideline, with web links.
  • List of LOS benchmarks by DRG for Medicare, commercial and Medicaid populations.


Guidelines

  • INT - Introduction
  • AI - Allergy & Immunology
  • AN - Anesthesia
  • BB - Blood Products; Transfusion; Phlebotomy; Apheresis
  • CAR - Cardiology; Vasculitis
  • CVS - Cardiovascular and Peripheral Vascular Surgery
  • CAM - Complementary and Alternative Medicine
  • DER - Dermatology
  • DM - Disposable Medical Supplies (DMS) and Durable Medical Equipment (DME)
  • ED - Medical Education and Training


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