Medical Review Criteria Guidelines 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
- AD - Addenda
- AI - Allergy & Immunology
- AN - Anesthesia
- BB - Blood Products; Transfusion; Phlebotomy; Apheresis
- CAM - Complementary and Alternative Medicine
- CAR - Cardiology; Vasculitis
- CVS - Cardiovascular and Peripheral Vascular Surgery
- DER - Dermatology
- DM - Disposable Medical Supplies (DMS) and Durable Medical Equipment (DME)
- ED - Medical Education and Training
- EM - Emergency and Critical Care Medicine
- END - Endocrine, Nutritional, Metabolic Diseases and Disorders
- ENT - Otolaryngology, Oral Surgery and Dental Services
- GEN - Genetic Disorders and Testing
- GI - Gastroenterology
- GND - Genetic Neuromuscular Disorders
- GS - General Surgery
- HO - Hematology & Medical Oncology
- INF - Infectious & Parasitic Disease
- INT - Introduction
- LAB - Laboratory
- MIS - Miscellaneous
- NEP - Nephrology
- NEU - Neurology and Neurosurgery
- NUC - Nuclear Medicine
- NUT - Nutritional Therapy
- OBG - Obstetrics and Gynecology
- OPH - Ophthalmology
- PED - Pediatrics
- PHM - Pharmacy
- POD - Podiatry (Foot and Ankle Disorders)
- PRS - Plastic and Reconstructive Surgery
- PUL - Pulmonary
- RAD - Radiology
- RMT - Rheumatology
- RT - Radiation Therapy and Radiation Oncology
- SM - Skeletal-Muscular System
- SP - Spinal Disorders; Procedures
- SUB - Substance Abuse
- UR - Urology
- VL - Vascular / Vasculitis
