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Medical Policies, Clinical UM Guidelines & Clinical Criteria, Clinical UM Guidelines and Clinical Criteria

UniCare specifically excludes coverage for services or supplies it determines to be investigational and/or not medically necessary. The UniCare State Indemnity Plan processes claims in accordance with these determinations, which are indicated in our Medical Policies, Clinical UM Guidelines & Clinical Criteria, clinical UM guidelines and clinical criteria.

The UniCare State Indemnity Plan follows all Medical Policies, Clinical UM Guidelines & Clinical Criteria and certain adopted clinical UM guidelines and clinical criteria.

Review all Medical Policies, Clinical UM Guidelines & Clinical Criteria and clinical UM guidelines.

Review clinical criteria

Prepayment Review program

UniCare has processes to review claims before and after payment, to detect fraud, waste, abuse and other inappropriate activity.

As part of UniCareís Prepayment Review program, clinical guidelines approved by the Medical Policy and Technology Assessment Committee, but not included in this standard adopted list, may be used to review a providerís claims. This may occur when a providerís billing practices are not consistent with other providers in terms of frequency or in some other manner. It may also occur when there is a need for provider education. In such instances, the clinical guidelines used for review of these providers are ďadoptedĒ for those indicated purposes.


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For self-funded plans, claims are administered by UniCare Life & Health Insurance Company. © 2000-2020 UniCare.