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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.

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.

  • CMS Medicare Coverage Database (Search page)
  • Simpra Utilization Management Clinical Guidelines
    • 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 – General). 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.

    • InterQual

      Simpra UM utilizes InterQual® criteria as a screening tool to assess whether acute hospital admissions are clinically indicated. InterQual® is an evidence-based clinical decision support solution for payers, providers, and government agencies who want to help ensure clinically appropriate medical utilization decisions. The first level screening using InterQual® is completed by a UM nurse. If the screening criteria are met, the nurse may approve the admission; however, if the screening criteria are not met, the admission is referred to a licensed physician (currently our Chief Medical Officer, or Medical Director) to determine clinical appropriateness. InterQual® cannot be used by nurses to deny hospital admissions – only a licensed physician can make a final determination regarding clinical appropriateness.  Simpra UM recognizes that InterQual® criteria can never address all the issues nor can it apply to every patient in every situation. Use of the criteria never replaces clinical judgment.

      Simpra also recognizes that InterQual® criteria is dynamic in that the subsets used, and criteria selected involve a case-by-case review and training to understand exactly how to utilize the platform. Simpra UM does provide full detail of any criteria utilized when making decisions regarding clinical appropriateness, and at no cost to you. If you would like a copy of the InterQual® subset and criteria selected to either approve, deny, or partially approve your hospital admission, please contact our UM department at 1-844-220-0408 and we will provide you a copy of our review of your hospitalization in detail within 24 business hours, or less.Please be aware that planned hospitalizations for elective procedures and surgeries are reviewed per the “CMS Inpatient Only List Addendum E”. Procedures that are payable only as inpatient are provided on this list and are approved for inpatient level of care as prescribed by CMS. You may access a list of the 2024 procedures here 2024 CMS Inpatient Only List.

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

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