Sources of Utilization Management Criteria for GEHA’s ...

Sources of Utilization Management Criteria for GEHA's Standard Option, High Option and HDHP Plans

Type of service

Inpatient hospitalization (including Residential Treatment Centers)

Contracted entity/Internal UnitedHealthcare Choice Plus Network: Delaware, Florida, Oklahoma, Louisiana, Maryland, North Carolina, Texas, Virginia, Washington D.C., West Virginia or Wisconsin

Source of Utilization Management Criteria for medical necessity determination

Milliman, UnitedHealthcare Commercial policy, ASAM (American Society of Addiction Medicine)

SNF, LTAC, rehab

Spinal pain management, spinal surgery

All other states not listed above.

UnitedHealthcare Choice Plus Network: Delaware, Florida, Oklahoma, Louisiana, Maryland, North Carolina, Texas, Virginia, Washington D.C., West Virginia or Wisconsin All other states not listed above. UnitedHealthcare Choice Plus Network: Delaware, Florida, Oklahoma, Louisiana, Maryland, North Carolina, Texas, Virginia, Washington D.C.,

Milliman Care Guidelines, ASAM (American Society of Addiction Medicine) Milliman, UnitedHealthcare Commercial policy

Milliman Care Guidelines UnitedHealthcare Commercial policy

Revised 031521

CM-OTH-0117-001

Oncology ? Outpatient chemotherapy and radiation

West Virginia or Wisconsin

Orthonet & GEHA

Milliman Care Guidelines, GEHA Corporate Medical policy created by referencing nationally accepted standards from professional societies, peer-reviewed medical literature, and an external panel of subject matter experts. terms/#criteria

Oncology Analytics

FDA, national societal guidelines, Medicare national and local coverage determinations, state-specific Medicaid policies, medical literature, and compendia recommendations. GEHA's drug coverage policy requirements, where applicable.

ABA therapy Pharmacy reviews

Radiology review

Genetic testing review

All other treatments, services or supplies

Optum CVS/Caremark

eviCore

eviCore

UnitedHealthcare Choice Plus Network: Delaware, Florida, Oklahoma, Louisiana, Maryland, North Carolina, Texas, Virginia, Washington D.C., West Virginia or Wisconsin

All other states not listed above.

Optum Behavioral Health Clinical Policy The Standard of Care per clinical literature, FDA labeling, specialty societies, external clinical experts. Nationally accepted standards from professional society recommendation, peer-reviewed literature, and subject-matter experts. Nationally accepted standards from professional society recommendation, peer-reviewed clinical literature, and subject-matter experts. Milliman, UnitedHealthcare commercial policy

Milliman care guidelines, GEHA Corporate Medical policy created by referencing nationally accepted standards from professional societies, peer-reviewed medical literature, and an external panel of subject matter experts.

Revised 031521

CM-OTH-0117-001

GEHA uses Milliman Care Guidelines as well as national societal guidelines to lead our quality and health management programs. A list of the clinical guidelines is below:

Condition Acute Myocardial Infarction with ST Elevation

Acute Myocardial Infarction without ST Elevation

Asthma

Attention Deficit Hyperactivity Disorder (ADHD) Bipolar Disorder: Adults Bipolar Disorder: Children & Adolescents Cardiovascular Disease: Prevention in Women

Guideline

American College of Cardiology Foundation/American Heart Association

American College of Cardiology Foundation/American Heart Association

National Heart, Lung and Blood Institute, Global Initiative for Asthma

American Academy of Child and Adolescent Psychiatry

American Psychiatric Association

American Academy of Child and Adolescent Psychiatry

American Heart Association

Cardiovascular Disease: Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Disease Cholesterol Management

Chronic Obstructive Lung Disease

Depression/Major Depressive Disorder Diabetes Dietary Guidelines Heart Failure

Hemophilia and von Willebrand Disease

Human Immuno-deficiency Virus (HIV)

Hyperbilirubinemia in Newborns Hypertension

Lifestyle Management to Reduce Cardiovascular Risk Obesity

Physical Activity Preventive Services Schizophrenia

Sickle Cell Disease Spinal Stenosis Stable Ischemic Heart Disease

American College of Cardiology/American Heart Association

American College of Cardiology/American Heart Association

Global Initiative for Chronic Obstructive Lung Disease (GOLD)

American Psychiatric Association

American Diabetes Association

U.S. Department of Health and Human Services

American College of Cardiology/American Heart Association

World Federation of Hemophilia and National Heart, Lung and Blood Institute

HIV Medicine Association of the Infectious Diseases Society of America

American Academy of Pediatrics

Panel Members Appointed to the Eighth Joint National Committee (JNC8)

American Heart Association/American College of Cardiology

American Heart Association/American College of Cardiology/The Obesity Society

U.S. Department of Health and Human Services

Agency for Healthcare Research and Quality

American Psychiatric Association/Psychiatry Online Guideline Watch

National Heart, Lung and Blood Institute

North American Spine Society

American College of Cardiology/American Heart Association et al.

Revised 031521

CM-OTH-0117-001

Condition Substance Use Disorders Tobacco Use

Guideline American Psychiatric Association/Psychiatry Online U.S. Department of Health and Human Services

Revised 031521

CM-OTH-0117-001

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