Clinical Review Criteria
Clinical review criteria will minimally meet the following requirements:
Criteria will meet 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 will also be consistent with an efficient and effective
utilization of resources available to recipients.
Clinical review criteria shall be a defined set of medical decision standards that Schaller Anderson will use to make authorization determinations on a case-by-case basis for benefits and services provided to recipients, and will be 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 will be used when available from peer-reviewed medical literature or from professional medical organizations when appropriate.
Clinical review criteria will take into consideration individual circumstances of health care need and be used to administer and manage health care benefits and services based on medical need and presenting symptoms.
Clinical review criteria and changes in criteria will be communicated to providers and recipients at least 30 days in advance of any changes.
Clinical review criteria and practice guidelines for all NH Medicaid prior authorization services will be 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. SAMAI is responsible for administering peer-to-peer reviews for appeals related to Diagnostic Imaging denials.
Criteria shall be made available to providers during trainings and upon request.