UM Criteria

  • Utilization Management (UM) Policies & Procedures, as well as the UM Criteria used to authorize,

  • Modify, or deny healthcare services, will be made available upon request to providers, members, their designated representatives, and the general public.

  • The staff at My Family Medical Group accepts collect calls related to UM issues during normal business hours.

UM Criteria
Language assistance is available to discuss UM issues.
UM decision making is based only on appropriateness of care and service and existence of coverage
My Family Medical Group does not specifically reward practitioners or other individuals for issuing denials of coverage
Financial incentives for UM decision makers do not encourage decisions that result in underutilization

Clinical Criteria for UM Decisions

Application of Evidence Based Criteria

Download the official clinical criteria document used to support evidence-based utilization management decisions and medical necessity reviews.

Download PDF
UM Criteria

MCG

  • MCG is a nationally recognized clinical decision support tool used to guide evidence-based medical necessity determinations

Click here to view MCG clinical criteria