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Internal Clinical Coverage Criteria
Denver Health Medical Plan (DHMP) has published internal clinical coverage criteria for the following services:
Medicare Advantage Clinical Coverage Criteria
DHMP uses the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and Local Coverage Determination (LCDs) criteria for services requiring authorization.
Criteria Used for UM Decisions
Nationally-accepted, evidenced-based clinical criteria sets are used when available. In cases in which the service is not addressed in any of the referenced criteria the clinical reviewers send to the DHMP medical director for guidance. UM staff will provide copies of the criteria to providers and members upon request.
For the Medicare lines of business, National Coverage Criteria (NCD) and Local Coverage Criteria (LCD) criteria is used and is embedded within MCG Health Care Guidelines. In coverage situations where there is no NCD, LCD, or guidance in original Medicare Manuals, DHMP will defer to MCG or next available evidence based criteria.
American Society of Addiction Medicine (ASAM) criteria is also embedded within MCG Health Care Guidelines. ASAM criteria is a multidimensional assessment that takes into account the patient's needs, obstacles and liabilities, as well as their strengths, assets, resources, and support structure. This information is used to determine the appropriate level of care across a continuum.
This resource is useful in determining medical necessity for newer technology – criteria which are often not yet included in a national criteria set like MCG.
A software system that is a point-of-care medical resource. The UpToDate system is an evidence-based clinical resource.
The Colorado HCPF Benefits Collaborative is a set of Benefit Coverage Standards that have been approved by the Colorado State Medicaid Director and are in effect for the Medicaid lines of business and product
Used only by Colorado Access (COA) for Medicaid Behavioral Health (BH) UM Reviews. BH Utilization Management has been delegated to COA by DHMP.
- MCG Health™ Care guidelines.
- HCPF Billing Manuals, Durable Medical Equipment, Prosthetics and Supplies (DMEPOS), DME HCPCS Codes.
- HCPF Portal – Fee Tables.
DHMP may establish coverage guidelines for services for which there are no clear evidence based clinical criteria.
For all lines of business UM will review the Member Handbook for coverage determinations. The Member Handbook describes covered services based on member's plan, included and excluded coverage, and conditions for coverage.
General Guidelines
DHMP considers the member’s medical needs by using established health care guidelines based on medical evidence and state regulations to determine the appropriate frequency and/or quantity of the service(s) requested. The DHMP Physician Reviewer reviews all requests that do not meet these criteria
The coverage policies apply to the benefit plans administered by DHMP and may not be covered by all DHMP plans. Please refer to the member’s benefit document for specific coverage information. If there is a difference between this general information and the member’s benefit document, the member’s benefit document will be used to determine coverage. For example, a member’s benefit document may contain a specific exclusion related to a topic addressed in a coverage policy.
Coverage determinations for individual requests require consideration of:
- The terms of the applicable benefit document in effect on the date of service
- Any applicable laws and regulations
- Any relevant collateral source materials including coverage policies
- The specific facts of the request
Contact Health Plan Services to discuss plan benefits more specifically (303) 602-2100.