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  Clinical Policies - Categorical

# Category Title Description
75 Administrative Late Clinical Submissions To define a consistent procedure for the review and processing of treatment plans with dates of service that do not meet the filing time requirement as determined by the Plan Summary.
311 Administrative Reimbursement for Medical Records The purpose of this policy is to define reimbursement for medical record requests.
316 Administrative Timeframes of UM Decisions and Notification To define the timeframes for utilization management (UM) decisions and notification of those decisions.
320 Administrative Quality of Care To define Quality of Care issues and the process for handling of complaints.
368 Administrative Date Extensions To allow for up to a two week period of care beyond the currently approved duration of treatment without requiring the submission of a new Patient Summary Form.
371 Administrative Overlapping Submissions To summarize the procedure by which consecutive submissions that overlap treatment plans are reviewed and processed.
477 Administrative Negotiated Services This policy has been developed to describe the criteria that ACN Group, Inc. (OptumHealth) uses to conduct the negotiation of health care services with non-participating healthcare providers, when requested by client health plan members.
71 Coding Reporting Spinal Chiropractic Manipulative Treatment (CMT) Levels This policy describes the criteria approved by OptumHealth Care Solutions-Physical Health (OHCS-PH)for the reporting of chiropractic manipulative treatment (CMT) procedural code levels. This document is intended to inform healthcare provider decision-making concerning the reporting of spinal CMT levels. When applicable, this policy serves as the clinical criteria for utilization review (UR) determinations.
388 Coding Application of Manual Muscle Testing with Report (CPT 95831) To summarize the application of the current procedural code (CPT) 95831, Manual Muscle Testing with Report.
389 Coding Application of Range of Motion Measurements with Report (CPT 95851) To summarize the application of the current procedural code (CPT) 95851, Range of Motion Measurements with Report.
447 Coding Consultation on X-Ray Examination Made Elsewhere (CPT Code 76140) To define ACN Group, Inc.’s policy on the review and interpretation of plain-film radiographs taken by an outside entity.
62 Compliance Confidential Information The purpose of the confidentiality policy is to define for all departments, employees and committees of OptumHealth Care Solutions-Physical Health (OHCS-PH) those types of documents and information which shall be considered confidential.
303 Compliance Nonclinical Administrative Staff within the Utilization Review Process The purpose of this policy is to define the use of non-clinical administrative staff within the utilization review process.
304 Compliance Credentialing and Recredentialing of ACN Group, Inc. Clinical Reviewers The purpose of this policy is to ensure that all ACN Group, Inc. clinical reviewers for Utilization Management and Credentialing are credentialed and recredentialed in accordance with ACN Group, Inc.'s CRM Program and with URAC, NCQA and/or other regulatory, state or federal agencies.
310 Compliance Data Collection and Data Elements The purpose of this policy is to define the data elements ACN Group, Inc. (OptumHealth) uses in conducting utilization management processes i.e., utilization review and/or notification programs.
322 Compliance UM Auditing The purpose of this policy is to outline the UM auditing process and monitoring for compliance and consistency.
330 Compliance Clinical Review Criteria The purpose of this policy is to ensure that ACN Group, Inc. (OptumHealth) has written clinical review criteria, which are clearly documented, are reviewed appropriately, and are applied consistently during the utilization review decision-making process.
331 Compliance Approval of Utilization Data The purpose of this policy is to ensure that utilization data is reviewed and approved on a regular basis.
332 Compliance Denial, Adverse Determination and Coverage Denial The purpose of this policy is to define denial, adverse determination and coverage denials.
335 Compliance Clinical Review Criteria Resources This policy was developed to identify those sources, other than internally derived data, that are used as clinical (medical) criteria in rendering utilization management decisions.
336 Compliance Retrospective Clinical Review (Post-Service) This policy was developed to define the parameters for retrospective clinical utilization review.
337 Compliance Utilization Management Overview The policy was developed to describe the required process of utilization review used by ACN Group, Inc. and essential for compliance with applicable state, federal and agency requirements or mandates.
346 Compliance Ensuring Appropriate Utilization To encourage appropriate utilization management decisions by supporting ACN Group, Inc.'s position that no financial incentives are provided in decision making.
351 Compliance Adverse Determination Based on Failure to make a Determination and Provide Written Notice To define ACN Group Inc.'s (OptumHealth) policy in the event that Support Clinicians fail to make a determination and provide written notice within the appropriate timeframes.
354 Compliance Patient Records The purpose of this policy is to define patient records (also commonly referred to as patient files).
418 Compliance Emergent Care To define ACN Group, Inc.'s position in the administration of health care services for those patients requiring emergent care.
419 Compliance Monitoring of Over and Under Utilization Utilization Management is responsible to monitor over and under utilization of health care services.
429 Compliance Guidelines for Assessing Clinical Evidence in Policy Development This guideline describes the process whereby clinical evidence informs the development of utilization management policies.
484 Compliance Members' Rights and Responsibilities To define OptumHealth Physical Health’s expectations associated with member rights and responsibilities.
81 Determinations Extraspinal Manipulation and/or Mobilization This policy serves as the criterion for peer-reviewer decisions concerning extraspinal manipulation and/or mobilization therapy for the treatment of neuromusculoskeletal disorders. This policy also serves as a resource for peer-to-peer interactions in describing the position of OHCS-PH on the application of extraspinal manipulation/mobilization procedures for neuromusculoskeletal disorders.
[Plain Language Summary]
82 Determinations Extremity Manipulation Following Acute/Traumatic Joint Injury To promote patient safety in the treatment of extremity articulations.
84 Determinations Determination of Maximum Therapeutic Benefit This policy has been developed to describe the current evidence-basis for the determination of maximum therapeutic benefit (MTB) in the management of musculoskeletal disorders. [Plain Language Summary]
94 Determinations Guidelines for Safety to Deliver High Velocity Low Amplitude Manipulation to Specific Region To ensure the safety of proposed high velocity low amplitude manipulation to a region.
333 Determinations Durable Medical Equipment The purpose of this policy is to outline the UM process by which durable medical equipment are determined to be medically necessary.
342 Determinations Manipulative - Mobilization Treatment for Nonmusculoskeletal Disorders This new policy serves as the criterion for peer-reviewer decisions concerning spinal and extraspina manipulation/mobilization therapy for the treatment of non-musculoskeletal disorders. [Plain Language Summary]
348 Determinations Application of Clinical Algorithms To summarize the application of clinical algorithms.
350 Determinations Experimental and Investigational Services and Devices To describe the guidelines for processing submitted cases, where the intervention proposed is determined to be experimental and/or investigational.
357 Determinations Application of Clinical Review Criteria This policy was developed to define the application of clinical criteria in utilization review.
358 Determinations Definition and Application of Complicating Factors in the Utilization Management Process To define the term complicating factors and how they impact Utilization Management decisions.
362 Determinations Established Patient Re-evaluation This policy has been developed to describe the criteria that ACN Group, Inc. (OptumHealth) uses to conduct utilization review (UR) determinations concerning the appropriateness and/or medical necessity for reporting of established patient re-evaluations.
366 Determinations Denial of Services Not Covered By the Health Plan To state the criteria supporting coverage denials that provide no criteria for the denial other than the service is not covered.
367 Determinations Critical Data Elements To identify the data elements, which were determined to be critical in arriving at an adverse UM review decision, and their application to the anticipated outcome of approved services.
448 Determinations Application of Evidence-Based Policies and Position Statements To define the position of ACN Group, Inc. (OptumHealth) regarding the application of evidence-based policies and position statements.
449 Determinations Maintenance/Custodial Care To define ACN Group, Inc.’s position regarding the application of maintenance/custodial care in clinical practice. [Plain Language Summary]
472 Determinations Spinal Manipulative Therapy for the Treatment of Headache This new policy has been developed as the clinical criterion that describes ACN Group, Inc.'s position regarding the efficacy, risks and burdens associated with the use of spinal manipulative therapy for the treatment of headache.
[Plain Language Summary]
474 Determinations Patient Healthcare Records Documentation Requirements for Utilization Review and File Audits This policy describes the elements of documentation that healthcare providers are required to include in patient medical records as well as recommended elements.
479 Determinations Determining Homebound Status This policy has been developed to describe the criteria that OptumHealth uses to conduct utilization review (UR) determinations concerning the appropriateness and/or medical necessity for providing skilled professional services in the home setting.
483 Determinations Kinesiology (Kinesio) Taping This policy has been developed as the clinical criterion that describes the position of ACN Group, Inc. (OptumHealth) regarding the efficacy, effectiveness, risks and burdens associated with the use of kinesiology (kinesio) taping therapy.
[Plain Language Summary]
73 Imaging/Testing General Guidelines for the Use of Plain-Film Spinal Radiography This policy will define the indications and contraindications for utilization of AP and Lateral Plain View Radiographs.
359 Imaging/Testing Electrodiagnostic Testing This policy has been developed as the clinical criterion that describes the position of ACN Group, Inc. (OptumHealth) regarding the appropriate application of electrodiagnostic (electrophysiological) testing for the evaluation of neuromuscular disorders.
392 Imaging/Testing Diagnostic Spinal Ultrasound To clarify ACN Group, Inc.’s position regarding the application of spinal diagnostic ultrasound in clinical practice.
394 Imaging/Testing Thermography To clarify ACN Group, Inc.’s position regarding the application of thermography in clinical practice.
402 Imaging/Testing General Guidelines for use of Plain Film Extremity Radiography This policy will define the indications for utilization of extremity radiographs.
444 Imaging/Testing Competency in Electrodiagnostic Testing This policy has been developed to describe the criteria that ACN Group, Inc. (OptumHealth) uses to satisfy competency requirements in the performance and interpretation of electrodiagnostic testing.
480 Imaging/Testing Functional Capacity Evaluation This process document describes the ACN Group, Inc. (OptumHealth) methodology and requirements for the appropriate and safe application of Functional Capacity Evaluation (FCE) CPT code 97750.
481 Imaging/Testing Work Hardening This process document describes ACN Group, Inc. methodology and requirements for the appropriate and safe application of Work Hardening Programs CPT codes 97545 and 97546.
482 Imaging/Testing Work Conditioning This process document describes ACN Group, Inc. methodology and requirements for the appropriate and safe application of Work Conditioning Programs CPT codes 97545 and 97546.
88 Special Populations Diathermy Therapy To assure pediatric patient safety regarding diathermy therapies are essential.
90 Special Populations Guidelines for the Application of Electrical Muscle Stimulation Therapies for Pediatric Patients To assure pediatric patient safety regarding electrical therapies are essential.
91 Special Populations Guidelines for the Application of Mechanical Traction for Pediatric Patients Guidelines to help support clinicians assure pediatric patient safety regarding Mechanical Traction are essential.
96 Special Populations Application of Ultrasound for Pediatric Patients Guidelines to help support clinicians assure pediatric patient safety regarding ultrasound are essential.
74 Therapies Manipulation Definition Manipulation codes are not specific in terms of what grade of mobilization/ manipulation is being authorized.
302 Therapies Manual Therapy Techniques (CPT Code 97140) This policy has been developed to describe the criteria that ACN Group, Inc. (OptumHealth) uses to conduct retrospective utilization review (UR) of health care records, when claims have been submitted for the procedural code 97140 (Manual Therapy Techniques).
361 Therapies Guidelines for the Application of Active Therapeutic Procedures This policy has been developed to describe the current evidence-basis for the application of active therapeutic procedures (therapeutic exercise, neuro-muscular re-education and therapeutic activities) in the management of spine-related disorders.
363 Therapies The Application of Passive Therapeutic Modalities for Neuromusculoskeletal Disorders To summarize ACN Group, Inc.’s assessment of the evidence-based applications of passive therapeutic modalities in the clinical management of common neuromusculoskeletal conditions or complaints.
393 Therapies Spinal Manipulation Under Anesthesia To clarify ACN Group, Inc.’s position regarding the application of manipulation under anesthesia (MUA) in clinical practice. [Plain Language Summary]
473 Therapies Nonsurgical Spinal Decompression Therapy This policy has been developed as the clinical criterion that describes ACN Group, Inc.’s position regarding the efficacy, risks and burdens associated with the use of motorized traction devices for nonsurgical spinal decompression therapy. [Plain Language Summary]


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