Define the clinical question
Identify the service, level of care, procedure, treatment, continued stay, or coverage determination under review.
Home / Clinical Criteria & Guidelines
Clinical Criteria & GuidelinesUtilization Management Clinical Review Framework
Our physicians integrate applicable regulatory requirements, coverage policies, recognized decision-support criteria and patient-specific clinical judgment.
Criteria organize the review. Evidence informs the review. Physician judgment makes the determination. Physician judgment operates within the governing coverage framework and integrates authorized decision-support criteria, relevant evidence, and the complete patient-specific clinical record.
The right standard depends on the case
Coverage framework, payer, jurisdiction, service type, contract and clinical circumstances can all affect which resources are controlling or relevant.
Licensed Clinical Decision-Support Criteria
Structured clinical decision support for medical necessity, level of care and continued stay.
Used when authorized by the client programAuthorized Clinical Review Criteria
Evidence-based criteria used by many organizations for level-of-care and service review.
Used when authorized by the client programNCD & LCD
CMS national and Medicare Administrative Contractor local coverage determinations.
Explore NCD/LCD →Two-Midnight Framework
CMS hospital admission principles relevant to Medicare Part A patient-status review.
Explore Two-Midnight →Procedure Status / IPO
Current CMS procedure-status requirements incorporated into procedural admission review.
Explore procedure status →Health Plan Policies
Client-specific coverage requirements for procedures, tests, therapies and technologies.
Explore plan policies →Specialty Guidelines
Authoritative society guidance and clinical evidence for specialized questions.
Explore specialty guidance →Medical Necessity Process
See how we combine coverage framework, criteria, evidence and individual clinical circumstances.
View our process →Important: Proprietary clinical decision-support criteria are used only when appropriately licensed or authorized. Product-specific criteria are not reproduced on this website.
PHYSICIAN REVIEW WORKFLOW
How a physician review is built
A defensible utilization-management determination connects the clinical question to the governing framework, material facts, clinical trajectory, physician judgment, and a clearly documented rationale.
01 · CLINICAL QUESTION
Define the review question
Identify the service, level of care, continued stay, transition, or coverage issue requiring physician determination.
02 · GOVERNING FRAMEWORK
Identify the controlling requirements
Consider applicable plan benefits, contract requirements, CMS rules, NCD/LCD, medical policy, and authorized clinical review criteria.
03 · MATERIAL FACTS
Establish the clinical facts
Assess severity, treatment intensity, diagnostics, comorbidities, functional status, response to treatment, and clinically relevant risk.
04 · CLINICAL TRAJECTORY
Evaluate what changed
Review what was known at the decision point and whether the patient is improving, deteriorating, or still requiring skilled intervention.
05 · PHYSICIAN JUDGMENT
Apply patient-specific clinical judgment
Criteria and policies inform the review; the physician integrates them with the individual clinical circumstances documented in the record.
06 · DETERMINATION
Document the determination
State the supported outcome—such as approval, denial, level-of-care recommendation, continued stay, transition, or escalation—with a concise clinical rationale.
The diagnosis alone does not determine medical necessity. The determination follows the governing coverage framework, material clinical facts, intensity of services, clinical trajectory, and the patient’s individual circumstances.
Need physician review capacity?
Discuss ongoing coverage, overflow reviews, appeals, or a customized UM program.