Adopted Clinical Guidelines as of: January 1, 2024

Note: Any Clinical Guideline not included in this standard adopted list that is needed to complete an ASO group-specific review requirement will be considered Adopted for that ASO group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in this standard adopted list may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are Adopted for those purposes.

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