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IHCS Clinical Guidelines

Integrated Home Care Services (IHCS) performs delegated functions on behalf of our health plan clients for utilization management, claims, care coordination, provider selection, credentialing, and network management.

IHCS uses evidence-based clinical guidelines and medical literature from nationally recognized sources to make medical necessity determinations. The medical coverage policies outline the criteria our clinicians use to determine if a procedure is “medically necessary” and serve as a reference for IHCS delegated health plan members, participating physicians, and other health care professionals.

There are times when a Medicare statute, regulation, NCD or LCD does not fully establish coverage criteria. When that happens, IHCS defaults to MCG and/or standard of care guidelines to determine medical necessity.

Clinical Criteria / Guidelines

Centers for Medicare & Medicaid Services (CMS):

NCDs and LCDs:

Care Guidelines

MCG care guidelines are the intellectual property of MCG Health and access is strictly controlled. Users are not able to distribute any MCG content without the permission of MCG. By following these instructions, you will have access to view MCG care guidelines online.

Step 1 disclaimer: Select the “MCG Care Guidelines” link to where you will land on MCG disclaimer page. You must check the “Accept Terms and Conditions” box and select the “Accept and Proceed” button to continue to the next page.

Step 2 user information: Next you will be required to enter your first name, last name and to select the button the most closely aligns with your interest in MCG care guidelines. Then select “Next”.

Step 3 contact information: MCG will ask for your preferred way of receiving a verification code. Select from text message, email or telephone call then select “Next”.

Step 4 access code: Enter the code received via your preferred method.

Step 5: Click on the ► desired product to be a shown a list of MCG care guidelines selected for the client’s program.

Step 6: Click on the guidelines you wish to review. Copy/pasting, printing, or other methods of duplication are not allowed. Once finished, Select “Back to Guidelines” list or close your tab.

Decision Making Coverage Hierarchy

Medicare Advantage:

IHCS will use NCD’s/LCDs, Chapter 7 & 13 and if no policy exists, IHCS will default MA Plan Policy, and if no policy exists IHCS will default to MCG care guidelines and standard of care guidelines.

Medicaid:

For Medicaid, IHCS uses State specific applicable policies where available, and if no policy exists, IHCS defaults to Health Plan policy and then to MCG care guidelines.

Commercial and ACA:

Health Plan specific criteria, if applicable and if no policy exists, IHCS will default MCG care guidelines