Clinical policies and practice guidelines

External clinical guidelines

There may be more than one set of criteria available for any given procedure or service. Medical necessity determinations under the applicable health plan benefit are based on a hierarchy of clinical policies and care guidelines.

Criteria developed by the following external entities may be used as indicated or when no PacificSource clinical policy or applicable Medicaid or Medicare guideline exists.
 

Medicaid

• Oregon Prioritized List of Health Services
   

Medicare and Medicaid

• National Coverage Determination (NCD) and Local Coverage Determination (LCD)
   

Commercial and Medicare

Musculoskeletal

• Carelon Medical Benefits Management Clinical Appropriateness Guidelines
   

Commercial, Medicare, and Medicaid

• MCG Care Guidelines  

Radiology

• Carelon Medical Benefits Management Clinical Appropriateness Guidelines

Genetic testing

• Carelon Medical Benefits Management Clinical Appropriateness Guidelines

Substance use disorders

• American Society of Addiction Medicine (ASAM) Criteria via One Healthcare 

Level of care for primary mental health diagnoses

• For adults ages 19 years and older: The Level of Care Utilization Services Tool (LOCUS) by the American Association for Community Psychiatry
  • LOCUS Guide for Patients, Families, and Providers (PDF)
  • LOCUS: Evaluation Parameters (PDF)
  • LOCUS: Levels of Care Descriptions (PDF)
     
• For children and adolescents ages 6 to 18 years: The Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII) by the American Association for Community Psychiatry and the American Academy of Child and Adolescent Psychiatry
  • CALOCUS-CASII Guide for Patients, Families, and Providers (PDF)
  • CALOCUS-CASII Dimensions and Anchor Points for Level of Care/Service Intensity Scoring (PDF)
  • CALOCUS-CASII Level of Care/Service Intensity Definitions & Utilization Criteris (PDF)
     
• For children five years of age and younger: The Early Childhood Service Intensity Instrument (ECSII) by the American Academy of Child and Adolescent Psychiatry
  • ECSII Guide for Patients, Families, and Providers (PDF)