Utilization management

Clinical practice guidelines

MCC of AZ uses nationally accepted, evidence-based criteria, developed by specialty organizations, national policy committees (clinical practice guidelines) and/or industry recognized review organizations in addition to State or Federal criteria or regulations (as appropriate), medical policy or internally developed criteria, physician and clinical judgment to evaluate the necessity of medical and behavioral health services. 

MCC of AZ has adopted evidence-based clinical practice guidelines or protocols for a wide variety of medical conditions and services delivered in different medical and/or behavioral health settings. MCC of AZ has adopted MCG evidenced –based clinical practice guidelines for management of medical, behavioral, home health, and nursing facility services.

Medical criteria is approved and reviewed annually by the MCC of AZ Medical Management Committee and National Policy Committee. In accordance with 42 CFR §438.236 MCC of AZ utilizes ASAM criteria for medical necessity determinations for Addiction and Recovery Services. MCC of AZ utilizes proprietary diagnostic services criteria for imaging, sleep studies, and certain pain management procedures. These criteria sets are based on sound scientific evidence for recognized settings of care and used to decide the medical necessity and clinical appropriateness of services. If state law requires additional criteria, it is adopted into policy and used.

MCC of AZ adopts practice guidelines that meet the following requirements:

  • Are based on valid and reliable clinical evidence or a consensus of health care professionals and service providers in a particular field;
  • Consider the needs and preferences of the members;
  • Are adopted in consultation with providers; and
  • Are reviewed and updated periodically, as appropriate.

MCC of AZ disseminates any revised practice guidelines to all affected providers and, upon request, to members and potential members. The practice guidelines provide a basis for consistent decisions for utilization management, member education, coverage of services, and any other areas to which the guidelines apply.