Review Protocols (updated)
Thank you for providing quality, cost effective care to our members. Effective December 1, 2022, Health Plan of Nevada and Sierra Health and Life’s Medical Management and Clinical Review teams transitioned from MCG Guidelines to InterQual Guidelines to keep in line with UnitedHealthcare. The transition includes fully insured, self-funded commercial and Medicaid products. If you have any questions regarding this transition, please contact your provider advocate directly or call Provider Services at 702-242-7088 or 1-800-745-7065.
Please consider the following when accessing our medical policies:
- In cases where the Nevada market varies from the UHC version, HPN/SHL will continue to utilize customized policies that will be indicated by the Health Plan of Nevada and Sierra Health and Life logos.
- Although the UHC branded policies will indicate they apply to a specific line of business, they will be used for all HPN and SHL lines of business in Nevada.
- The links in the UHC Medical Policies may not pertain to Health Plan of Nevada and Sierra Health & Life members.
- When Medicaid is silent, HPN/SHL will utilize the commercial coverage criteria for Medicaid members. Please check the Nevada Medicaid Services Manual (MSM) or other state Medicaid documents as applicable.
- Due to the nature of medical technology, these policies are subject to be changed without notice.
- Effective 1-1-22, the process to request exceptions for oncology step therapy for members with stage 3 or stage 4 cancer will meet requirements of NV Senate Bill No. 290.
- Exception requests are to be submitted under urgent status and require the following information: progress notes, laboratory results, radiology results, previous medications, and other factors impacting the plan of care. Processing delays may occur if the requestor (e.g. rendering provider, ordering provider, or member) does not have appropriate documentation of medical necessity.
- Requests are reviewed by Registered Nurses, Pharmacists, and Board Certified Oncologists and will be processed in 72 hours or less if all required information is included in the request.
- The Step Therpy Exception request form can be accessed here.
The Health plan Provider Advocates can assist providers requesting additional information or clarification on medical policies.
UHC MEDICAL POLICIES:
PHARMACY POLICIES
The search engine below provides a full text search of all UHC Medical Policies
The links on the results page will take you to the appropriate policy on the UHC website.
