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The clinical criteria shown below are now available on our Medical Policy site. You can search by the policy number or name to easily find them.

New policy # Policy name
142 Air ambulance
146 Ground ambulance
158 Outpatient pediatric pain rehabilitation centers

We use InterQual® Criteria as a tool to make medical necessity determinations for certain medical services. The guideline below is now available in the InterQual Transparency Tool. To access the tool on our website, log in and go to Clinical Resources>Coverage Criteria & Guidelines>InterQual Criteria & SmartSheets. Then click Go Now.

For Use this InterQual subset
Private duty nursing Private duty nursing

On April 1, 2021, we retired our medical necessity criteria, Outpatient Chest PT and PT/OT Medical Necessity – Vestibular Rehabilitation.

Federal Employee Program

For members enrolled in the Federal Employee Program (FEP), be sure to visit fepblue.org. On the Medical Policies and Utilization Management Guidelines page, click the tab, Utilization Management Guidelines for guidelines including:

  • Inpatient Skilled Nursing Facility Services
  • Outpatient High Technology Diagnostic Imaging
  • Non-Emergency Air Ambulance Transport
  • Hearing Aids

Skilled Nursing Facility Services (FEP Standard Option)

Policies for FEP members can differ substantially from policies for members of commercial or Medicare Advantage plans. Skillled Nursing Facility services for FEP Standard Option members are one example. Refer to the resources below for help following our guidelines.

 Step-by-Step Guide for Skilled Nursing Facilities
Frequently Asked Questions

Related Resources

 Payment policies (log in and go to Office Resources>Policies & Guidelines>Payment Policies)

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