Utilization Management Clinical Criteria

Welcome to the Utilization Management Clinical Criteria page. Inland Empire Health Plan (IEHP) has created UM Subcommittee Approved Authorization Guidelines to serve as one of the sets of criteria for medical necessity decisions. Our goal in creating this page is to provide you with easily accessible electronic versions of IEHP’s UM guidelines. IEHP utilizes a variety of sources in developing our UM guidelines which include:

• Medicare and Medi-Cal’s coverage policy statements
• Evidence in the peer-reviewed published medical literature
• Technology assessments and structured evidence reviews
• Evidence-based consensus statements
• Expert opinions of healthcare Providers
• Evidence-based guidelines from nationally recognized professional healthcare organizations and public health agencies.

IEHP is also licensed to use Apollo Medical Review Criteria and InterQual to guide utilization management decisions.

Since medical technology is constantly evolving, our clinical guidelines are subject to change without prior notification. Additional UM Subcommittee Guidelines may be developed as needed or may be withdrawn from use.

Please note that benefits may vary based on member’s line of business; therefore, certain services discussed in the UM Subcommittee Guidelines may not be a covered benefit.

Providers may obtain information about criteria, either in general or relating to specific UM decisions, from IEHP upon request by contacting the IEHP UM Department. Please contact the IEHP Provider Relations Team at (909) 890-2054 to be connected to the UM Department.

In accordance with regulatory requirements from the Centers for Medicare and Medicaid Services (CMS), all Utilization Management Clinical Criteria are also accessible to the public at the external links listed below.

Usage Disclaimer:

IEHP uses MCG care guidelines to help review medical necessity for health service requests. MCG care guidelines are the protected intellectual property of MCG. IEHP is not able to distribute them without the permission of MCG. MCG has provided a tool that allows IEHP members and prospective members to view relevant MCG care guidelines; however, you will not be able to print them.

Access instructions:

Step 1: Click the "Clinical Care Utilization Management Guidelines" link to access the MCG care guidelines, read the disclaimer, and accept the terms and conditions.

Step 2: Complete the User Information form.

Step 3: Complete the verification process to continue.

Step 4: Click on the arrow icon to expand the list of guidelines in the content group.

Step 5: Click on the guideline you wish to view.

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.