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Utilization Review Criteria

Medical necessity decision-making requires the consistent application of utilization criteria. Arise Health Plan uses both nationally published and locally developed criteria. Input from Arise Health Plan practitioners, including department chairs and other practitioners, is solicited. The Medical Policy Committee reviews criteria for appropriateness and makes recommendations for approval to the Quality Improvement Committee. The Quality Improvement Committee makes the final decision to approve criteria for use. Decision making criteria is reviewed and updated annually or more frequently if significant changes in standards of care are identified.

Criteria are applied consistently to medical necessity decisions, and in a manner that is responsive to individual customer needs and the characteristics of the local delivery system. At least annually, Arise Health Plan evaluates the consistency with which Case Management Specialists and the Medical Director apply the criteria when making decisions. A corrective action plan is developed if significant variation is found.

The following criteria used by Arise Health Plan are, but not limited to:

  • Milliman Care Guidelines, for In-patient and Surgical Care, Ambulatory Care (Medical and Behavioral health and Chiropractic Care), General Recovery and Chronic Care
  • Hayes Medical Technology Directory
  • Mercy Conference Guidelines, Cochraine Collaborative Systemic Reviews and CCGPP for Low Back Pain (for Chiropractic Care)
  • DSM-V Criteria (Behavioral Health)
  • Medical Policy Committee Decisions (Coverage Policy Bulletins)
  • Pharmacy Benefit Criteria (includes clinical data, reference materials, expert physician opinion, FDA-approved labeling, and/or cost-benefit information)
  • APTA Guide to Physical Therapy Practice
  • Apollo Managed Care Guidelines

Arise Health Plan practitioners/providers may review Medical Management criteria. If requested, a copy of specific criteria used for decision-making is provided to an Arise Health Plan practitioner. This copy is for the practitioner’s own use, and may not be released to others without permission from the Arise Health Plan. Arise Health Plan practitioners are informed of the process to request criteria during practitioner orientation and the provider newsletter.

The Medical Director, or designee attempts to contact the attending practitioner prior to making an in-patient medical necessity denial. The Medical Director’s phone number is provided to the ordering practitioner when a medical necessity denial is made for outpatient care.


Policies are statements that define how Arise Health Plan intends to administer its Medical Management program. Medical Management policies are presented to the Quality Improvement Committee for review. Each department is responsible for development of procedures for functions within its responsibility.

Clinical Experts

In addition to the Medical Director, Medical Management has access to clinical experts through Arise Health Plan’s Practitioner panel, many of whom participate on various committees at Arise Health Plan and are board-certified. Arise Health Plan also purchases a variety of expert services through external vendors. Examples of expert external reviews used are:

  • Medical Review Institute of America (MRIoA)
  • Diplomat/ARC
  • Magellan/NIA

External Review

The Medical Director, or designee, consults with board-certified practitioners when appropriate, to accommodate the medical necessity review process. Access is also provided to external review agencies that employ board-certified practitioners for case review.