Clinical Coverage Criteria

Fallon Health Weinberg's Care and Utilization Management uses national, evidence-based criteria that are reviewed annually by a committee of health plan and community-based physicians. This group determines the medical appropriateness of selected services requested by physicians and other providers. These criteria are approved as being consistent with generally accepted standards of medical practice, including prudent layperson standards for emergency room care.

We also develop in-house medical and behavioral health criteria, making use of local specialist input and current medical literature, as well as guidelines from the Centers of Medicare & Medicaid Services (CMS) and the State of New York.

Criteria are available upon request.