Utilization Management on Availability of Criteria, Public Accessibility & Statement of Rationale

Utilization Management Statement on Availability of Criteria

Affinity Medical Group will disclose Utilization Management Policies, procedures, and criteria used to authorize, modify, or deny healthcare services to members or person designated by members upon request by contacting the department below:

Utilization Management Department
510-662-3410

Public Access to MCG Clinical Guidelines used to make decisions on Utilization Management authorizations

Affinity Medical Group – Great Affordable Healthcare for the East BayAffinity Medical Group

Statement of Rationale

Affinity Medical Group (AMG) makes Medicare Advantage medical necessity determinations in accordance with all medical necessity determination requirements, outlined at § 422.101(c)1 ; based on the circumstances of each specific individual, including the patient’s medical history, physician recommendations, and clinical notes; and in line with all fully established Traditional Medicare coverage criteria. This includes established criteria in applicable Medicare statutes, regulations, National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). When Medicare coverage criteria are not fully established, AMG will utilize publicly accessible internal criteria that are based on current evidence in widely used treatment guidelines or clinical literature.