Policy/Procedure Title |
Policy Number |
Utilization Management Program Description
|
MPUD3001
|
Acupuncture Services Guidelines
|
MCUG3002
|
Acute Inpatient Administrative Days
|
MCUP3053
|
Appeals of Utilization Management / Pharmacy Decisions
|
MCUP3037
|
Provider Request for Appeal of UM Decision for Medical Necessity Determination
|
MCUP3037-A
|
Member Authorization for Provider Appeal
| MCUP3037-B |
UM Appeal Acknowledgement Letter
| MCUP3037-C |
Appropriate Service & Coverage (Over / Under Utilization)
|
MPUP3006
|
Authorization of Ambulatory Procedures and Services
|
MCUG3007
|
Treatment Authorization Request (TAR) Form Reference
|
MCUG3007-A
|
TAR Requirements
|
MCUG3007-B
|
PHC-Supplemental PHC requirements for medical necessity for Pain Management Procedures
|
MCUG3007-C
|
Behavioral Health Treatment (BHT) for Members Under the Age of 21 (previously Autism Spectrum Disorder) | MPUP3126 |
CalAIM Community Supports (CS)
| MCUP3142
|
Community Supports Criteria Matrix and Community Supports HCPCS Code Chart
| MCUP3142-A
|
CalAIM Service Authorization Process for Enhanced Care Management (ECM) and/or Community Supports (CS)
| MCUP3143
|
Community Supports Criteria Matrix and Community Supports HCPCS Code Chart
| MCUP3143-A
|
Enhanced Care Management (ECM) HCPCS Code Chart
| MCUP3143-B
|
Community Support Services Referral Form
| MCUP3143-C
|
Cardiac Rehabilitation
|
MCUP3128
|
Chiropractor Services
|
MCUG3010
|
Communication Services
|
MCUP3064
|
Community Based Adult Services
|
MCUP3115
|
CBAS Individual Plan of Care (IPC) Form DHCS 0020
| MCUP3115-A
|
Coordination of Care for Members in Foster Care
|
MCUP3103
|
Criteria and Guidelines for Utilization Management
| MCUP3139 |
Table of Approved Criteria and Guidelines Referenced for Utilization Management
| MCUP3139-A |
Criteria for Home Health Services
|
MCUG3011
|
Delegation of Inpatient Utilization Management
| MCUP3141 |
Dental Services (including Dental Anesthesia)
|
MPUP3048
|
Direct Members
| MCUP3039
|
Direct Members Designation Grid
| MCUP3039-A
|
Discharge Planning (Non-capitated Members)
|
MCUP3012
|
DME Authorization
|
MCUP3013
|
DME Rental Only
|
MCUP3013-A
|
DME Limited to Special Circumstances
|
MCUP3013-B
|
Oxygen (O2) Request Verification Form
|
MCUP3013-C
|
Certificate of Medical Necessity for all Durable Medical Equipment (DME)
|
MCUP3013-D
|
MTU DME Review Process and Example Form
| MCUP3013-E
|
Eating Disorder Management Policy
| MCUP3145
|
Emergency Services
|
MCUP3014
|
Evaluation and Management of Obstructive Sleep Apnea in Adults
|
MCUG3110
|
External Independent Medical Review | MCUP3138 |
Family Planning By-Pass Services
|
MCUP3015
|
Fecal Microbiota Transplant
| MCUP3136 |
Gender Dysphoria / Surgical Treatment
|
MCUP3125
|
Genetic Screening and Diagnostics
|
MCUP3131
|
Genetic Testing Requirements
| MCUP3131-A |
Family History Screening Tool
| MCUP3131-B |
Health Services Review of Observation Code Billing
|
MPUP3018
|
Hearing Aid Guidelines
|
MCUG3019
|
Documentation for Authorization of Hearing Aids
| MCUG3019-A |
Hospice Services Guidelines
|
MCUP3020
|
Hospital Bed / Specialty Mattress Guidelines
|
MCUG3134
|
Incontinence Guidelines
|
MCUG3022
|
PHC Maximum/Average Benefit Guidelines
|
MCUG3022-A
|
Incontinence Supplies Medical Necessity Certification form (DHCS 6187)
|
MCUG3022-B
|
Inpatient Utilization Management
|
MCUG3024
|
Insulin Infusion Pump & Continuous Glucose Monitor Guidelines
|
MPUG3025
|
| MPUG3025-A
|
CCS NL 15-1222 Continuous Glucose Monitoring (CGM) Systems as a CCS/GHPP Program Benefit - Revised 12/23/2022
| MPUG3025-B
|
Inter-Rater Reliability Policy
|
MPUP3026
|
Long Term Care SSI Regulation
|
MCUP3051
|
Medical Abortions
|
MCUP3050
|
Patient Agreement Form
|
MCUP3050-A
|
Sample Letter to Partnership HealthPlan of California from provider
|
MCUP3050-B
|
Medical Nutrition Services
|
MCUP3052
|
Referral Guidelines for Children/Adolescents
|
MCUP3052-A
|
Referral Guidelines for Adults
|
MCUP3052-B
|
Adult Body Mass Index
|
MCUP3052-C
|
Mental Health Services
|
MCUP3028
|
Adult Screening Tool for Medi-Cal Mental Health Services
| MCUP3028-A |
Youth Screening Tool for Medi-Cal Mental Health Services
| MCUP3028-B
|
Transition of Care Tool for Medi-Cal Mental Health Services
| MCUP3028-C
|
Nebulizer Guidelines
|
MPUG3031
|
Negative Pressure Wound Therapy (NPWT) Device/Pump
|
MPUP3059
|
Neonatal Circumcision
|
MCUP3121
|
Orthotic and Prosthetic Appliances Guidelines
|
MCUG3032
|
Osteopathic Manipulation Therapy
|
MCUP3130
|
Pain Management Specialty Services
|
MCUP3049
|
TAR Requirements
|
MCUP3049-A
|
PHC Medical Necessity Criteria for Pain Management Procedures
|
MCUP3049-B
|
Palliative Care: Intensive Program
|
MCUP3137
|
Palliative Care Eligibility Assessment
| MCUP3137-A |
Certification of Terminal Illness
| MCUP3137-B |
Engagement and Intensive Home-Based Palliative Care Enrollment Process
| MCUP3137-C |
Application to be a Contracted Intensive Home-Based Palliative Care Provider
| MCUP3137-D |
Palliative Care: Pediatric Program for Members Under the Age of 21
| MCUP3140
|
Outpatient Pediatric Palliative Care Eligibility Assessment
| MCUP3140-A
|
Engagement & Enrollment Process for Outpatient Palliative Care
| MCUP3140-B |
Application to be a Contracted Outpatient Palliative Care Provider
| MCUP3140-C
|
PCP-To-PCP Transfers & Assignments of New Members to PCP
|
MCUP3034
|
Physical, Occupational and Speech Therapies
|
MCUP3114
|
Podiatry Services
|
MPUP3129
|
Positron Emission Tomography Scans (PET Scans)
|
MPUP3116
|
Prenatal & Perinatal Care
|
MCUG3118
|
Preoperative Day Review
|
MPUP3035
|
Pulmonary Rehabilitation
|
MCUP3111
|
Pulmonary Rehabilitation Questionnaire
| MCUP3111-A |
Referral to Specialists (RAF) Policy
|
MCUP3124
|
Rehabilitation Guidelines for Acute and Skilled Nursing Inpatient Services
|
MCUP3003
|
Residential Substance Use Disorder Treatment Authorization
| MCUP3144 |
Review Guidelines for Member Placement in Long Term Care (LTC) Facilities
| MCUG3038
|
Bed Hold & Change of Status Report Form
| MCUG3038-A
|
BedHold / TAR Process After Acute Hospitalization Flowchart (Archived June 12, 2024)
| MCUG3038-A |
Admissions for Short Term Rehab or Short Term Skilled Nursing (Archived June 12, 2024)
| MCUG3038-B |
Bed Hold & Change of Status Report form
(Archived June 12, 2024)
| MCUG3038-C
|
Second Medical Opinions | MPUP3078 |
Screening and Treatment for Substance Use Disorders (previously Alcohol & Substance Abuse Screening & Treatment)
| MCUP3101 |
Alcohol Misuse Screening & Counseling (AMSC) Training Resources
| MCUP3101-A |
Pocket Screening and Brief Intervention for Alcohol Use Disorders
| MCUP3101-B |
Application to be a Contracted Brief Intervention / Referral to Treatment Provider
| MCUP3101-C |
Review Documentation for Application to Become a Contracted Behavioral Counseling Intervention / Referral to Treatment Provider
| MCUP3101-D |
Youth Pocket Screening and Brief Intervention for Alcohol Use Disorders
| MCUP3101-E
|
Sterilization Consent Protocol
|
MCUP3119
|
Street Medicine
| MCUP3146
|
Technology Assessment
|
MCUP3042
|
Review of New Medical Technology Form
|
MCUP3042-A
|
Telehealth Services
|
MCUP3113
|
Transplant Authorization Process
| MCUP3104
|
Treatment Authorization Request (TAR) Review Process
| MCUP3041 |
TAR Requirements
| MCUP3041-A |
Tuberculosis Related Treatment
|
MCUP3047
|
TB Screening Guidelines (Flowcharts)
| MCUP3047-A
|
Urgent Care Services
|
MCUP3044
|
Utilization Review Guidelines ICF/DD, ICF/DD-H, ICF/DD-N Facilities
|
MCUG3058
|
Bed Hold/TAR Process
|
MCUG3058-A
|
Vision Care
|
MCUP3102
|
Waiver Programs
|
MCUP3106
|
Wheelchair Mobility, Seating & Positional Components
|
MCUP3133
|
