Utilization and Quality Management Guidelines

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American Specialty Health Affiliates (ASHA) is charged, through its role as a health plan and network, to:

ASHA defines generally accepted standards of practice as those based on peer-reviewed, published research data, the educational standards accepted by the majority of the profession’s educational institutions, and reliable case studies that are core to the profession. Practices and protocols that are incorporated into baseline education, competency training, and certification or licensure testing requirements of the profession’s regulators (e.g., national and state boards and/or certifying entities) are also considered contributory to generally accepted standards of practice. The following definitions are applied:

Generally Accepted Standards of Medical1 Practice:

Generally Accepted Standards of Medical Practice means standards that are based on Credible Scientific Evidence published in peer-reviewed Medical Literature generally recognized by the relevant medical community2, Physician and Healthcare Provider Specialty Society recommendations, the views of Physicians and Healthcare Providers practicing in relevant clinical areas and any Other Relevant Factors.

Credible Scientific Evidence:

Credible Scientific Evidence is clinically relevant scientific information used to influence the diagnosis or treatment of a patient that: meets industry standard research quality criteria, is adopted as credible by an ASHA clinical peer review committee, and has been published in an acceptable peer reviewed literature published in clinical science sources.

Medical Literature:

Medical Literature is clinically relevant clinical science information published in an acceptable peer reviewed literature published in clinical science sources.

Healthcare Provider Specialty Society:

A Healthcare Provider Specialty Society is a society of specialty providers that represents a significant numbers of practicing practitioners or other academic or clinical research institutions for that specialty.

Other Relevant Factors:

Other relevant factors are (a) specific evidence supported provider opinions and (b) professional judgments on clinical activities that represent a consensus opinion from the Medical Community.

ASHA maintains a Clinical Services Management Program and Quality Improvement Program in accordance with nationally recognized accreditation organization standards, payor delegation requirements and applicable state and federal laws and regulations. ASHA verifies Covered Services are Medically Necessary Services through its Clinical Services Management Program. ASHA evaluates the quality of services through its Quality Improvement Program in order to ensure the delivery of safe and clinically effective services to members and enrollees. Contracted practitioners participate in these programs by providing the necessary information for the clinical evaluation of services and by documenting and demonstrating clinical performance in accordance with professionally recognized standards of practice. Selected contracted practitioners also participate on clinical peer review committees responsible for review and approval of clinical policy, as well as credentialing, utilization management, quality management, and member grievance decisions.

Clinical decisions are made by ASHA in support of its Clinical Services Management Program and Quality Improvement Program in accordance with the guidelines and criteria described in its policies, including but not limited to:

Clinical Practice Guidelines

Clinical Policies

ASHA also developed individual Clinical Practice Guidelines (CPGs) related to specific techniques, procedures and technologies.Techniques or procedures identified by ASHA clinical peer review committees as implausible or as having a poor benefit:safety profile are listed on policy CR7 Clinical Procedure Determinations. Use of the techniques or procedures listed on CR 7 Clinical Procedure Determinations is cause for failure to meet ASHA criteria for network participation.