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Medical Policies, Clinical Criteria, and Clinical Utilization Management (UM) Guidelines

UniCare specifically excludes coverage for services or supplies it determines to be investigational and/or not medically necessary. The UniCare State Indemnity Plan follows all Medical Policies, Clinical Criteria, and certain adopted Clinical UM Guidelines, and processes claims in accordance with these determinations.

Effective for dates of service on and after March 1, 2019, new clinical criteria will be included in our clinical criteria review process. The drugs that require prior authorization will continue to require prior authorization notification with UniCare.

Prepayment Review Program

UniCare has processes to review claims before and after payment, to detect fraud, waste, abuse and other inappropriate activity.

As part of UniCare's Prepayment Review program, clinical guidelines approved by the Medical Policy and Technology Assessment Committee, but not included in this standard adopted list, may be used to review a provider's claims. This may occur when a provider's billing practices are not consistent with other providers in terms of frequency or in some other manner. It may also occur when there is a need for provider education. In such instances, the clinical guidelines used for review of these providers are "adopted" for those indicated purposes.