Internal Coverage Policy

Providence is delegating the responsibility for Utilization Management from contracted managed care (HMO) health plans. Providence follows the clinical guidelines set forth by Medicare and our contracted health plans. The guidelines provided are used by Providence Saint John to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and benefits covered under your plan. In situations where there are no available guidelines from the health plan, the delegated entity may adopt internal coverage policies approved by the health plans. Adopted internal coverage policies will comply with CMS guidance (refer to CMS Manual Chapter 4 section 90.5) MCM Chapter 4 (cms.gov) and are updated based off evidence-based guidelines and research. They are publicly accessible under Internal Coverage Guidelines seen below.

Guidelines

Providence Health utilizes the Care Guidelines to determine medical necessity for the plans that we manage. The Guidelines are the protected intellectual property of MCG. Providence Health is not able to distribute them without the permission of MCG. MCG has provided a tool that allows Providence Health members and prospective members to view relevant MCG guidelines, however you will not be able to print them.

Follow the instructions below to access the MCG Guidelines:

  1. Access guidelines above, read the disclaimer, and accept the terms and conditions.
  2. Complete the User information form.
  3. Complete the verification process to continue.
  4. Click on the arrow icon.
  5. Click on the guidelines you wish to view.