Clinical Criteria for Utilization Management (UM) Decision-Making
Reviewed and approved by the Utilization Management Policy Committee (UMPC) on December 16, 2025
Medicare Clinical Criteria and Guidelines:
The following criteria were adopted on December 16, 2025, by the Champion Health Plan Utilization Management Policy Committee (comprised solely of physicians) for the purpose of making medical coverage decisions (organization determinations).
The clinical guidelines and criteria were selected and adopted because they were developed by Medicare to ensure that health plan members receive appropriate medical coverage in every situation. These criteria are always utilized first when making a medical coverage decision. Other criteria are only utilized when there is no Medicare guideline covering the member’s health care needs.
In the Absence of Medicare Guidelines:
These secondary clinical criteria (listed below) were adopted by the Champion Health Plan Utilization Management Policy Committee (comprised solely of physicians) on December 16, 2025, to be utilized when there are no Medicare clinical criteria or guidelines available for making medical coverage decisions (organization determinations). These criteria will be utilized in the sequence that they are listed.
These clinical guidelines were selected and adopted because they represent “industry standard.” They are evidence based, recognized, and accepted throughout the health care industry as some of the best criteria available to ensure the best possible outcomes for members. Physicians also consider each member’s situation and health care needs when making medical coverage decisions.
The clinical guidelines and criteria were selected and adopted because they were developed by Medicare to ensure that health plan members receive appropriate medical coverage in every situation. These criteria are always utilized first when making a medical coverage decision. Other criteria are only utilized when there is no Medicare guideline covering the member’s health care needs.
Medical Policy from Member’s Health Plan (delegating to Champion MSO)
See website for member’s health plan to access the criteria and guidance per member.
- American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Guidelines
- American Academy of Orthopedic Surgeons (AAOS) Guidelines
- American Academy of Ophthalmology (AAO) Guidelines
- American Academy of Neurology (AAN) Guidelines
- American Heart Association (AHA) Guidelines
- American College of Radiology (ACR) Guidelines
- Infectious Disease Society of America (IDSA) Guidelines
- U.S. Preventative Services Task Force (USPSTF) Preventative Care Guidelines
If you would like additional information, please call Champion at 1-800-885-8000 and ask for the UM Department between 8 am and 8 pm Monday-Sunday between October 1st and March 31st ; and 8 am to 8 pm Monday through Friday from April 1st – September 30th.