Medical Policies & Clinical UM Guidelines
Welcome to Empire’s Medical Policies & Clinical Utilization Management (UM) Guidelines website. Our goal in creating this application is to provide you with ready access to electronic versions of medical policies and clinical UM guidelines.
How to Find Medical Policies & Clinical UM Guidelines
The tabs on this page are organized as follows:
Clinical UM Guidelines
You can locate a medical policy or clinical UM guideline by clicking on the By Category or By Alpha options under each tab. The By Category page lists each category as a link at the top of the page. To view a specific category, click the category link to be redirected. The By Alpha page lists all medical policies or clinical UM guidelines alphabetically by title. There is an alpha index at the top of the page. To find a title, click the appropriate letter to be redirected.
You can also use the “search” feature, which is now housed in the top navigation, or by clicking the link below.
Search for Medical Policies & Clinical UM Guidelines
Consumer Tools are a new group of documents that offer information on certain health services and procedures for which a review may occur based on Medically Necessary, Not Medically Necessary, Investigational, Cosmetic and Reconstructive criteria. Consumer Tools provide background information related to benefit decisions and also describe possible positive considerations and risks that will have to be weighed, to support care that is safe and appropriate. The documents also include questions that a doctor may wish to review with her/his patients, our members. We hope that these documents can help enhance the discussion between doctors and their patients (our members), to support informed health care choices related to some of our medical policies and clinical UM guidelines. To help find out if a health service and/or treatment will be covered, and to learn more about the member’s plan benefits, see the certificate of coverage or call the customer service number on the member ID card.
Customizations to MCG™ Care Guidelines (formerly Milliman Care Guidelines®)
This document provides a summary of customizations to the MCG™ Care Guidelines (formerly Milliman Care Guidelines®) 16th Edition (effective May 21, 2012).
This document provides a summary of customizations to the MCG™ Care Guidelines (formerly Milliman Care Guidelines®) 17th Edition (effective May 6, 2013).
ICD-10 Coding (Effective October 1, 2014)
In preparation for the implementation of ICD-10 CM and ICD-10 PCS, we are updating medical policies and clinical UM guidelines on a quarterly basis to include proposed ICD-10 coding. The ICD-10 coding is available through either a hyperlinked Appendix or a listing of applicable ICD-10 codes within the Coding section. Please note that at this time, the ICD-10 code list may not be all inclusive and is subject to change as Position Statements may be updated. Feel free to send comments regarding the ICD-10 coding using the Contact Us link below.
The following contact us e-mail address is for questions related to the research and development of medical policies and clinical Utilization Management (UM) guidelines found on this site. For those inquiries please use the following link: Contact Us
Please direct inquiries related to benefit coverage, new ID cards, billing practices, prior authorization, pre-determination or reimbursement and any other inquiries unrelated to medical policy or clinical guidelines to the local plan provider representative, billing/reimbursement department or Customer Service, as applicable, by calling the number listed on the member ID card. We will not be able to respond to those inquiries.