Medical Criteria under Medicare and Medicaid

Priority Health Medicaid
For Medicaid members, Priority Health Government Programs follows:

• InterQual® guidelines as indicated under Medical Criteria in this manual
• The State and Federal laws and guidelines regarding coverage and benefits when appropriate. 

Priority Health Medicaid has specific medical policies that address benefits that are specific to Medicaid/MICHILD members.  The medical policies are reviewed annually or more frequently if necessary and approved by the Medical Affairs Committee.


Priority Health Medicare
For Medicare plan members, Priority Health Government Programs follows:

• National and local coverage determinations, and
• The Benefits Manual published by the Centers for Medicaid and Medicare (CMS) regarding coverage and benefits. 

These publications are reviewed and approved annually by the Medical Affairs Committee.  Priority Health's Medical Policies are utilized if these publications require medical necessity to be met but do not specifically address criteria.