Clinical Review Criteria
Clinical review criteria will minimally meet the following requirements:
Criteria are nationally-recognized standards of quality medical care and services.
Criteria are consistent with the provision of appropriate care, at an appropriate
time, in an appropriate setting by an appropriate provider and at an appropriate
level of care. Criteria are consistent with an efficient and effective utilization
of resources available to recipients.
Clinical review criteria are defined set of medical decision standards that Schaller Anderson uses to make authorization determinations on a case-by-case basis for benefits and services provided to recipients, and are based on established medical policy and clinical practice guidelines approved by the NH Medicaid Program. Visit the NH Medicaid Administrative Rules page.
Evidence-based criteria are used when available from peer-reviewed medical literature or from professional medical organizations when appropriate.
Clinical review criteria take into consideration individual circumstances of the recipients health care need and are used to administer and manage health care benefits and services based on medical need and presenting symptoms.
Clinical review criteria and practice guidelines for all NH Medicaid prior authorization services are reviewed at least annually. DHHS shall approve SAMAI’s clinical review criteria and any changes to the criteria will be put forth in administrative rules.
Criteria used for decision making shall be made available to providers during trainings and upon request.