Utilization Management (UM) Clinical Criteria Hierarchy
L.A. Care uses clinical criteria for decisions used within Utilization Management and or delegated PPG/IPAs. This is for our Medi-Cal, Medicare Plan, L.A. Care Covered, L.A. Care Covered Direct, and PASC-SEIU Health Plan. View the Clinical Criteria Hierarchy.
Clinical Validations Guidelines (for payment integrity)
L.A Care uses Payment Integrity – Clinical Validation Guidelines that refers to ensuring that payments made for health care services are accurate, appropriate, and in compliance with applicable regulations and standards.
Clinical validation guidelines play a critical role in maintaining payment integrity by verifying that the medical services provided are necessary, properly documented, and billed according to accepted clinical and coding standards.
- Acute Respiratory Failure Clinical Validation Guideline
- Encephalopathy Clinical Validation Guideline
- Malnutrition Clinical Validation Guideline
- Renal Failure Clinical Validation Guideline
- Sepsis & SIRS Clinical Validation Guideline
- Skilled Nursing Facility Clinical Guidelines
- Myocardial Ischemia & Infarction Guideline
Medical Necessity Guidelines
Utilization management (UM) applies "medical necessity guidelines" as defined by the criteria used to determine if a healthcare service or procedure is considered medically necessary, ensuring that treatments are appropriate, effective, and aligned with accepted medical standard.