Internal Coverage Policy

Providence is delegating the responsibility for Utilization Management from contracted managed care (HMO) health plans. Providence follows the clinical guidelines set forth by Medicare and our contracted health plans. The guidelines provided are used by Providence Saint John to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and benefits covered under your plan. In situations where there are no available guidelines from the health plan, the delegated entity may adopt internal coverage policies approved by the health plans. Adopted internal coverage policies will comply with CMS guidance (refer to CMS Manual Chapter 4 section 90.5) MCM Chapter 4 (cms.gov) and are updated based off evidence-based guidelines and research. They are publicly accessible under Internal Coverage Guidelines seen below.

Guidelines

Providence Health utilizes multiple Care Guidelines to determine medical necessity for the plans that we manage. The Guidelines are the protected intellectual property of MCG and InterQual. Providence Health is not able to distribute them without the permission of MCG or InterQual. MCG and InterQual have provided tools that allows Providence Health members and prospective members to view relevant MCG and InterQual® Guidelines; however, you will not be able to print them.

Follow the instructions below to access either the MCG or InterQual Guidelines:

  1. Access guidelines above, read the disclaimer, and accept the terms and conditions.
  2. Complete the User information form.
  3. Complete the verification process to continue.
  4. Click on the arrow icon.
  5. Click on the guidelines you wish to view.

MCG Guidelines

Choose your region: 

InterQual Guidelines

Transparency tool (all regions)

CalOptima Health's Physician-Administered Drug Prior Authorization Required List

CalOptima Health communicates pharmaceutical restriction/preferences annually and after updates to members and prescribing practitioners. CalOptima Health's Physician-Administered Drug Prior Authorization Required List can be accessed through the link below: