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South Carolina Healthy Connections

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July 2018 Medical Policies and Clinical Utilization Management Guidelines Update

October 31, 2018

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing prior authorization requirements have not changed.

Note:

  • Effective November 1, 2018, AIM Specialty Health® (AIM) Musculoskeletal Level of Care Guidelines, Sleep Study Guidelines and Radiology Guidelines will be used for clinical reviews.
  • When requesting services for a patient (including medical procedures and medications), the Precertification Look-Up Tool may indicate that prior authorization is not required, but this does not guarantee payment for services rendered; a Medical Policy or Clinical UM Guideline may deem the service investigational or not medically necessary. In order to determine if services will qualify for payment, please ensure applicable clinical criteria is reviewed prior to rendering services.

Please share this notice with other members of your practice and office staff.

To search for specific policies or guidelines, visit www.BlueChoiceSCMedicaid.com and select Providers.

Medical Policies

On July 26, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Healthy Blue.

View the bulletin to see the full Medical Policies table.

Clinical UM Guidelines

On July 26, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Healthy Blue. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on August 31, 2018.

View the bulletin to see the full Clinical UM Guidelines table.

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