Welcome to the Utilization Management Criteria page. IEHP has created UM Subcommittee Approved Authorization Guidelines to serve as one of the sets of criteria for medical necessity decisions. Our goal in creating this page is to provide you with easily accessible electronic versions of IEHP’s UM guidelines.   

IEHP utilizes a variety of sources in developing our UM guidelines which include:

 Medicare and Medi-Cal’s coverage policy statements

 Evidence in the peer-reviewed published medical literature

 Technology assessments and structured evidence reviews

 Evidence-based consensus statements

 Expert opinions of healthcare providers

 Evidence-based guidelines from nationally recognized professional healthcare organizations and public health agencies.

IEHP is also licensed to use InterQual and Apollo Medical Review Criteria to guide in utilization management decisions.

Since medical technology is constantly evolving, our clinical guidelines are subject to change without prior notification. Additional UM Subcommittee Guidelines may be developed as needed or may be withdrawn from use. 

Please note that benefits may vary based on Member’s line of business; therefore, certain services discussed in the UM Subcommittee Guidelines may not be a covered benefit.

You will need Adobe Acrobat Reader 4 or later to view the PDF files. You can download a free copy by clicking below.

 Table of Contents

 Denial Matrix