Prior Authorization Guidelines & Criteria

Prior Authorization Guidelines & Criteria ONECare Medicare Health Plan

Prior Authorization Guidelines
Medical/Dental/Behavioral Health Covered Services Prior Authorization Requirements
(Effective 04/01/2019).
Prior Authorization Criteria

ONECare uses clinically sound, nationally developed and accepted criteria for making medical necessity decisions. Clinical criteria utilized in decision making include, but is not limited to:

  • CMS Guidelines
  • MCG Guidelines
  • AHCCCS Guidelines
  • American College of Obstetrics and Gynecology
  • The American Academy of Pediatrics
  • WellCare Clinical Care Guidelines (CCG’s)
  • ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 3rd edition

Note: There is no prior authorization for Behavioral Health Crisis Services

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