Clinical Criteria for Health Utilization Management Decisions

New Century Health applies nationally recognized clinical criteria and standards of care to medical necessity reviews. As available, CMS National and Local Coverage Determination Criteria and Medicare Guidance and CMS recognized Compendia are utilized for Medicare Advantage service requests. Health Plan specific clinical policies and nationally recognized oncology and cardiology consensus guidelines and compendia are applied for Commercial member reviews.

Clinical criteria utilized to issue an authorization are available upon request by contacting the NCH Health Utilization Department at:

New Century Health
675 Placentia Avenue, Suite 300
Brea, CA 92821
(888) 999-7713, option 1

Affirmative Statement

New Century Health’s policy states that utilization review decisions are based only on medical necessity, appropriateness of care and service and the existence of coverage. There are no rewards, bonuses or incentives for practitioners or other individuals for issuing denials or approvals of coverage, service or care. There are no financial incentives for utilization management decision makers to encourage decisions that would result in underutilization or over-utilization. All medical necessity determinations are based upon nationally recognized standards of care and clinical guidelines and are not influenced by financial or in-kind incentives.