Clinical Policies

AmeriHealth Caritas VIP Care is dedicated to providing the most comprehensive, outcomes-driven health solutions for our members. Part of this approach means making it a priority to reduce unnecessary variations in care. We've used the latest scientific evidence and research to create the Clinical Practice Guidelines, which represent the latest in current professional standards.

AmeriHealth Caritas VIP Care makes decisions on coverage based on the Centers for Medicare & Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member's medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Corporate clinical policies.

Hierarchy of Clinical Review used by the Utilization Management Medical Review team is listed below:

  1. Benefit Coverage Contract
  2. National Coverage Determinations (NCDs)
  3. Local Coverage Determinations (LCDs)
  4. Medicare Administrative Contractors (MAC)
  5. Medicare Coverage Articles
  6. Delegated LOB Clinical Criteria/Policies
  7. AmeriHealth Caritas Corporate Clinical Policies
  8. Adopted preventive and clinical practice guidelines

While these guidelines are intended to inform, they aren't intended to replace a physician's clinical judgment. The physician remains responsible for determining the applicable treatment for each individual.

For more information about the Clinical Policies, or to learn about AmeriHealth Caritas VIP Care's disease management and preventive care programs, call Provider Services at 1-800-521-6007.

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