Healthcare Management General Information
HCM Contact Information
HCM Holiday Schedule
HCM Clinical Review Criteria AR CODE #14220, A.C.A. 23-99-1105(a)
HCM UM Program Overview
Clinical Guidelines
Clinical Criteria (Password Required) AR CODE #14220, A.C.A. 23-99-1105(a)
Clinical Guideline Library CA CODE #30219, 10144.52(e)
Introduction to Evidence-Based Clinical Review Criteria & Mental Health Parity CA CODE #30219, 10144.52(e)
Introduction to Clinical Review Criteria
ASAM Criteria
State Statistical Data
Luminare Health Arkansas Statistical Claim Data AR CODE #14220, A.C.A 23-99-1105(d)
Plan Precertification Requirements
Individual Medical Tennessee Plan Enrollees TN CODE 18827, 56-6-705(c)
MetLife (Delaware American) Pre-certification Requirements OH CODE 17463, 3923.041(11)(a)
Plan Documents
The Ohio State University Health Plan Document OH CODE 17463, 3923.041(11)(a)
Bellefontaine City Schools Med COVID-19 Memorandum OH CODE 17463, 3923.041(11)(a)Bellefontaine City Schools PHE Update OH CODE 17463, 3923.041(11)(a)
Bellefontaine City Schools Med Plan Document OH CODE 17463, 3923.041(11)(a)
City of Delaware Ohio UM Plan Requirements OH CODE 17463, 3923.041(11)(a)
City of Delaware Ohio HSA Plan Document OH CODE 17463, 3923.041(11)(a)
City of Delaware COVID-19 Memorandum OH CODE 17463, 3923.041(11)(a)
City of Delaware Premium Plan Document OH CODE 17463, 3923.041(11)(a)
City of Delaware Premium Plan Document Amd 1 Ohio HSA Plan Document OH CODE 17463, 3923.041(11)(a)
City of Delaware Premium Plan Document Amd 2 Ohio HSA Plan Document OH CODE 17463, 3923.041(11)(a)
City of Delaware Base PPO and HSA Plan Document OH CODE 17463, 3923.041(11)(a)
City of Delaware PHE Update Memorandum OH CODE 17463, 3923.041(11)(a)
Highland District Hospital_Med_Plan Doc_Draft 2_010124 OH CODE 17463, 3923.041(11)(a)
Maryland Treatment Plan 15-10B-06(e)
Memorial Hospital/Memorial Gables Ohio UM Plan Requirements OH CODE 17463, 3923.041(11)(a)
Forms
State Pre-authorization Forms
AZ Standard Prior Authorization Form for Health Care Services § AZ Stat 20-2534
AZ Standard Prior Authorization Form for Medication, DME and Medical Devices § AZ Stat 20-2534
California: Prescription Drug Prior Authorization or Step Therapy Exception Form CA CODE #19367, 10 CCR § 2218.30(d)
Texas Standard Prior Authorization Request Form TX CODE 13275, 28 TAC 19.1810(d)
Texas Prescription Drugs Prior Authorization Request Form TX CODE 14099, 28 TAC 19.1820(d)