Tools and information to help improve the provider experience and member health outcomes
Clinical Practice Guidelines and Medical Necessity
Clinical Practice Guidelines
The following clinical practice guidelines are intended to support our health care team and serve as resources to ensure our providers have the most up-to-date, evidence-based information recommended by nationally recognized organizations.
These are resources you may find beneficial in care of our members. Some of these sources may require a subscription.
- AMDA: The Society for Post-Acute and Long-Term Care Medicine – the standard care process in the post-acute and long-term care (PA/LTC) setting. https://paltc.org/product-type/cpgs-clinical-practice-guidelines
- COPD: Global Strategy for the Diagnosis, Management and Prevention of COPD. Clinicians – Global Initiative for Chronic Obstructive Lung Disease – GOLD (goldcopd.org)
- Diabetes: Standards of Medical Care in Diabetes—2022 Abridged for Primary Care Providers | Clinical Diabetes | American Diabetes Association (diabetesjournals.org)
- Heart Failure: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure https://www.ahajournals.org/doi/epub/10.1161/CIR.0000000000001063
- Hypertension: ACC and American Heart Association (AHA) guidelines for the detection, prevention, management, and treatment of high blood pressure. https://www.acc.org/guidelines/hubs/high-blood-pressure
- Alzheimer’s Association Dementia Care Practice Recommendations https://www.alz.org/professionals/professional-providers/dementia_care_practice_recommendations
- American Psychiatric Association – Practice Guidelines on the use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia https://www.physiciansweekly.com/aace-releases-2020-update-clinical-practice-guidelines-for-postmenopausal-osteoporosis
- Centers for Medicare & Medicaid Services
National Partnership to Improve Dementia Care in Nursing Homes | CMS
- Osteoporosis: 2020 Clinical Practice Guidelines for Postmenopausal Osteoporosis https://www.physiciansweekly.com/aace-releases-2020-update-clinical-practice-guidelines-for-postmenopausal-osteoporosis
Guidelines are provided for informational purposes only and are not meant to direct individual treatment decisions. All patient care and related decisions are the sole responsibility of providers. These guidelines do not dictate or control a provider’s clinical judgement regarding the appropriate treatment of a patient in any given case.
“Medically Necessary” or “Medical Necessity” means health care services or supplies that a physician, exercising prudent judgement, would provide and/or order for a patient. The services must be:
- in accordance with generally accepted standards of medical practice;
- clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
- not primarily for the convenience of the patient, physician, or other health care provider, and
- not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease
Simpra Advantage utilizes the following Medical Necessity criteria to guide utilization management decisions. This may include, but is not limited to, decisions involving inpatient reviews, prior authorizations, level of care, and retrospective reviews.
- CMS Medicare Coverage Database (Search page)
- HPG-01_Skill in Place:
Simpra Advantage Plan Utilization Management department authorizes Skill in Place (Part A) services for enrollees who meet Centers for Medicare and Medicaid Services (CMS) criteria for skilled services as specified in chapter eight of the Medicare Benefit Policy Manual (8.30 – Skilled Nursing Facility Level of Care – Genera). Skill in Place is a unique service provided to enrollees living in skilled nursing facilities who are not post-acute, (recently discharged from an inpatient hospitalization) but require skilled services to prevent an acute hospitalization or visit to an emergency department. The Skill in Place guideline was created as a tool to assist skilled nursing facilities in their decision to start a Simpra Enrollee on Skill in Place services.
- HPG-02_Home Health:
Simpra Advantage Plan Utilization Management department authorizes home health services for enrollees who meet Centers for Medicare and Medicaid Services (CMS) criteria for skilled services in their home (Medicare Benefit Policy Manual, Chapter 7- Home Health Services, Section 20- Conditions to be Met for Coverage of Home Health Services, Section 30- Conditions Patient Must Meet to Qualify for Coverage of Home Health Services). The Home Health guideline was created as a tool for contracted home health agencies to refer to when starting care for Simpra members. Simpra does not require prior authorization for home health agencies to initiate care for Simpra members and the Home Health guideline walks the home health agency through when and how to submit their request for authorization of services to care for our members.
Simpra Advantage Medical Necessity criteria does not supersede state or Federal law or regulation.