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Clinical Practice Guidelines

Umpqua Health adopts Clinical Practice Guidelines that are based on valid and reliable clinical evidence and/or a consensus of clinical experts. They consider the needs of the member and are adopted in consultation with our Clinical Advisory Panel and network providers. They are also reviewed and updated periodically as appropriate.

Medical

Behavioral, Mental Health & SUD

Pharmacy

Our Pharmacy team has taken the latest guidelines and have created easy-to-use management tools that align with current medications on the UHA Formulary.

PROVIDER

Have a Recommendation?

If you would like to recommend a Clinical Practice Guideline for UHA to review in the next Clinical Advisory Panel, please complete the form below.

Prior Authorization Guidelines

In addition to the Clinical Practice Guidelines above, UHA uses the following criteria for utilization management decisions (prior authorizations):

  • Medicare Local Coverage Determination (LCD) and National Coverage Determination (NCD)
  • Prioritized List of Health Services (PLHS): The Oregon Health Evidence Review Commission (HERC) ranks health care condition and treatment pairs in order of clinical effectiveness and cost-effectiveness. See the list here.
  • Guideline Notes: Using the Prioritized List for the line of coverage, based upon ICD-10, CPT, and HCPCS codes, UHA will then find the associated Guideline Note for treatment. These guidelines can be found here.
  • InterQual®: InterQual® is an evidence-based clinical decision support tool used to make clinically appropriate medical utilization decisions.. Documentation of the InterQual® criteria is included in each PA used to make a determination in CIM, which can be accessed by CIM users.
  • Oregon Administrative Rules (OAR) can be found here.
  • Up-to-Date ® Wolters Kluwer: UpToDate is an evidence-based clinical decision support resource at the point of care.
  • American Society of Addiction Medicine (ASAM): The ASAM Criteria is the most widely used and comprehensive set of guidelines for placement, continued stay, transfer, or discharge of patients with addiction and co-occurring conditions.
  • Functional Rating Index© Institute of Evidence-Based Chiropractic
  • AllMed: Contracted Independent Review Organization UHA uses for evaluation of high cost DME or for any Expert Specialty review.
  • CMS Inpatient Hospitalization List

Learn more about Prior Authorizations at Umpqua Health.