Clinical Criteria
Evidence-based clinical decision rules governing prior authorization approvals
| Criteria Name | Service Type | Source | Evidence | Auto-Approve Condition | Status | Expand |
|---|
Search criteria...
Evidence-based clinical decision rules governing prior authorization approvals
| Criteria Name | Service Type | Source | Evidence | Auto-Approve Condition | Status | Expand |
|---|
Clinical criteria are evidence-based rules that determine when prior authorization is automatically approved or requires manual review.
Higher evidence levels (A/B) carry more weight in coverage decisions and appeal processes.
The Status toggle activates or deactivates each rule. When disabled, all requests for that service type go to manual review. Click Expand on any row to see:
Use the Import buttons to pull updated clinical guidelines directly from MCG or InterQual feeds. Imported criteria are mapped automatically to service types. Review and activate imported criteria before they go live.