Clinical review criteria means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services.
Clinical review criteria means the written screens, decision rules, medical protocols, or guidelines used by the carrier as an element in the evaluation of medical necessity and appropriateness of requested admissions, procedures, and services under the auspices of the applicable health plan.
Examples of Clinical review criteria in a sentence
Clinical review criteria may be obtained by calling 1-888-888-4742 ext.
Clinical review criteria represent the basis for non-certification utilization review determinations.
Clinical review criteria are the screening procedures, protocols, and practice guidelines that a health plan issuer uses to make coverage decisions.
Clinical review criteria are employed in conjunction with support clinician judgment to arrive at determinations regarding the medical necessity of the requested services, the appropriate level of the requested services, and the outcome of care (for continuing care).
Clinical review criteria are applied in conjunction with the specific circumstances applicable to each patient’s condition.
More Definitions of Clinical review criteria
Clinical review criteria means the written screening procedures, decision abstracts, clinical protocols, and clinical practice guidelines used by a health plan issuer or utilization review organization to determine whether or not health care services or drugs are appropriate and consistent with medical or scientific evidence.
Clinical review criteria means written screening proce- dures, decision abstracts, clinical protocols, and clinical practice guidelines used by an insurer, pharmacy benefit manager, or uti- lization review organization to determine whether health care ser- vices are medically necessary and appropriate.
Clinical review criteria means the same as defined in section 514J.102.
Clinical review criteria means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by a carrier or utilization review organization to determine the medical necessity and appropriateness of health care services.[PL 2019, c. 295, §1 (NEW); RR 2019, c. 1, Pt. A, §26 (RAL).]
Clinical review criteria means the written screening procedures,