UCare's Medical Necessity Guidelines

UCare medical necessity guidelines are available to assist in the determination of medical necessity for certain clinical procedures (procedure, therapy, diagnostic test, medical device, etc.) where coverage requires determination of medical necessity.

UCare determines medical necessity using clinical criteria, UCare authored medical policies and guidelines developed by authoritative external sources, such as InterQual®, Magellan clinical care guidelines and the National comprehensive Cancer network. These criteria and guidelines are not a substitute for clinical judgment by a qualified health care professional and do not constitute the practice of medicine or medical advice. The treating health care professional remains responsible for diagnosis and treatment. Patients should always consult their treating health care professional before making decisions about medical care.

 

How Medical Guidelines Are Used 

When making coverage decisions, UCare staff apply the benefits associated with that member's enrollment and eligibility, according to federal and state regulations and member specific evidence of coverage (EOC), member contract or member handbook. If a determination of medical necessity is required and criteria are not specified in benefits or regulations, UCare will apply clinical criteria, which may be from UCare Medical Policies or authoritative external sources such as InterQual®, Magellan clinical guidelines or the National Comprehensive Cancer Network.

UCare offers members and providers access to utilization review staff: during business hours (612-676-6705 or 1-877-447-4384 toll free, Monday - Friday, 8 a.m. to 5 p.m.) and a voice mail box to leave messages after hours (phone: 612-676-6705 or fax: 612-884-2499). Hearing impaired members can call our TTY text machine at 612-676-6810 or 1-800-688-2534 toll free. Collect calls are accepted. Language assistance is available from Customer Services.

Medical drug policies are still available and can be viewed on the Provider Pharmacy page.