Clinical Guidelines

Clinical Coverage Guidelines
Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.

Clinical policies may have either a WellCare or a “Centene” heading. WellCare utilizes clinical policies for those medical technologies, procedures or pharmaceutical treatments for which InterQual criteria does not exist. InterQual is a nationally recognized evidence-based decision support tool. In addition, WellCare may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual criteria is payable by WellCare.

Clinical Practice Guidelines
Clinical Practice Guidelines (CPG) are best-practice recommendations based on available clinical outcome and scientific evidence. WellCare Clinical Practice Guidelines reference expert professional and clinical society recommendations, ensuring that the guidelines contain the highest level of evidence-based content. Clinical Practice Guidelines are also used to guide efforts to improvement the quality of care in our membership.