Provider Resources

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
• Dementia:
  • 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.

Medical Necessity

“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.

• Centers for Medicare and Medicaid (CMS) Criteria
• InterQual

Simpra Advantage Medical Necessity criteria does not supersede state or Federal law or regulation.