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Medical Policies

Independent Health has developed clinical guidelines to establish evidence-based clinical criteria for utilization management decisions. We may delegate utilization management decisions of certain services to third-party organizations which may adopt their own clinical criteria.

Clinical guidelines apply to certain policies. Clinical guidelines apply to members enrolled in Medicare Advantage plans only if there is no criteria for the specific service in a Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of a prior authorization request. View the NCDs and LCDs on CMS’ Medicare Coverage Database.

Coverage of services is subject to the terms, conditions, limitations of a member’s policy and applicable state and federal law.

If you have questions or need policy information

To confirm coverage or eligibility, please refer to your coverage policy documents (e.g., Certificate/Evidence of Coverage, Schedule of Benefits) or contact Independent Health.

Looking for drug related information? View our Pharmacy Policies.

Looking for information related to radiology services (CT, MRA, MRI, non-cardiac PET)? View the Radiology Policies.