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CLINICAL PRACTICE GUIDELINES

CGHC Clinical Policies

Your COC describes the standard by which medical procedures and services are determined to be Covered Health Services.  For a service to be covered, it must be “Medically Necessary.”  As a part of determining whether a particular service is medically necessary, we look to Generally Accepted Standards of Medical Practice.  We base which services we consider to be Medically Necessary on these standards and develop clinical policies that provide the criteria under which the necessity is evaluated.

We will provide you or your healthcare provider with the specific criteria upon request.  Please know that the criteria is very specific as to the condition being treated, and the method of treatment.  We can provide instruction to your provider with the information she/he needs to properly submit a procedure for review or appeal.

 

CGHC’s Clinical Practice Guidelines

Common Ground Healthcare Cooperative (CGHC) adopts Clinical Practice Guidelines from recognized medical associations and voluntary and national health organizations to assist practitioners with clinical decision making and help improve quality of care and outcomes. Guidelines are selected based on their scientific evidence and sponsored by recognized and appropriate clinical sources.

CGHC’s Medical Management committee is responsible for selecting and approving Clinical Practice Guidelines. Selected guidelines are relevant to an entire population or a portion of the population that is at high risk for certain diagnoses or conditions.

To optimize the use of guidelines by practitioners:

  • Guidelines are adopted for at least two medical conditions and at least two behavioral conditions;
  • A clinical basis is established for each guideline;
  • Two of the guidelines are the basis for CGHC’s disease management programs;
  • The guidelines support acute disease treatment protocols, chronic condition management programs or quality performance measurement.

CGHC reviews Clinical Practice Guidelines every two years and updates them as needed. Reviews take place more frequently when new scientific evidence or national standards are published.

CGHC’s Clinical Practice Guidelines serve as the basis of CGHC’s disease management programs. They help practitioners maintain consistent standards when providing care for acute, chronic and behavioral health conditions. They are not meant to replace clinical judgment or to be all-inclusive. Each practitioner is responsible for assessing individual patients and developing an action plan to meet each patient’s needs. CGHC members are encouraged to discuss their care with their doctors to develop a care plan and achieve the best possible results.