NHS Clinical Utilization Management Guidelines
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Nevada Health Solutions (NHS) uses Clinical Utilization/Management Guidelines (U/M Guidelines) to determine the medical necessity of requested medical services. The U/M Guidelines include medical policies developed by NHS (Medical Policies) as well as the following MCG Care Guidelines®: Inpatient and Surgical Care Guidelines®; General Recovery Care Guidelines®; and Ambulatory Care Guidelines® (together, the MCG Care Guidelines®).
The Medical Policies are posted here for informational purposes only. The Medical Policies are written for a medical professional audience. Individuals should discuss any information they read in the Medical Policies with their treating health care professionals. The Medical Policies do not constitute, and should not be taken as, medical advice or medical care. NHS does not provide, and is not responsible for, any medical advice, diagnosis, or treatment.
Ultimately, benefit determinations are subject to all terms and conditions of the individual’s applicable health plan, including specific exclusions and limitations, as well as to applicable state and/or federal law. The U/M Guidelines, including the Medical Policies and MCG Care Guidelines®, do not constitute, and should not be taken as, plan authorization or an explanation of benefits. Because health plans vary in coverage, some plans may not provide coverage for certain services that are addressed in the U/M Guidelines.
The U/M Guidelines are subject to change at any time without notice. However, NHS will make reasonable efforts to keep the Medical Policies, as posted on this web site, updated. Health plan members should contact their local customer services representatives for specific coverage information. NHS does not allow the Medical Policies to be copied, printed or downloaded from this web site for any reason.
The licensed standard and customized MCG Care Guidelines® are the property of MCG Health, LLC, and are not posted on this web site. If you would like to request a paper copy of a specific section of the Medical Policy, MCG Care Guidelines®, or another section of the U/M Guidelines, you may contact Nevada Health Solutions.Continue