Medical Necessity and Clinical Criteria
McLaren Health Plan partners with InterQual® to create clinical criteria or standards to determine the medical necessity and appropriateness of health care services.
Clinical criteria help ensure that health care services are evidence based and objective. Clinical criteria are not used to deny care. Clinical criteria can help improve health outcomes and may also help reduce the cost of services.
Refer to InterQual® for the below clinical criteria guidelines: https://prod.ds.interqual.com/service/connect/transparency?tid=dc31b123-941a-4127-a79e-44d2eb3980d5
World Professional Association for Transgender Health (WPATH) criteria may be used in addition to InterQual criteria. WPATH criteria are listed here: https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644
Refer to the MDHHS Medicaid Provider Manual for the following clinical criteria guidelines: https://www.michigan.gov/mdhhs/doing-business/providers/providers/medicaid/policyforms/medicaid-provider-manual
Additional Information and Resources
Medicaid Prior Authorization list:
mclarenhealthplan.org/Uploads/Public/Documents/HealthPlan/documents/MHP%20Documents/Service-Codes-Requiring-Preauthorization.pdf
Utilization Management Annual Reporting
The Centers for Medicare and Medicaid Services (CMS) requires health plans to publish certain utilization data on their website for members and providers. Utilization data is related to how quickly we process authorization requests. The required data is presented in the table below:
Medicaid
| Item |
Calendar Year
2025 |
| Total standard prior authorization requests received |
135573 |
| Total expedited prior authorization requests received |
31209 |
| Total standard and expedited prior authorization requests received |
166782 |
| Percentage of standard prior authorization requests that were approved |
71.28% |
| Percentage of standard prior authorization requests that were denied |
28.72% |
| Percentage of standard prior authorization requests approved after appeal |
0.38% |
| Average time to decision for standard prior authorizations (days) |
5.08 |
| Median time to decision on standard prior authorizations (days) |
2 |
| Percentage of expedited prior authorization requests that were approved |
93.90% |
| Percentage of expedited prior authorization requests that were denied |
6.00% |
| Average time to decision for expedited prior authorizations (hours) |
22 |
| Median time to decision for expedited prior authorizations (hours) |
19 |
| Percentage of total prior authorization requests approved with an extended timeframe |
0% |
MHP Community (Individual)
| Item |
Calendar Year
2025 |
| Total standard prior authorization requests received |
510 |
| Total expedited prior authorization requests received |
328 |
| Total standard and expedited prior authorization requests received |
838 |
| Percentage of standard prior authorization requests that were approved |
90% |
| Percentage of standard prior authorization requests that were denied |
10% |
| Percentage of standard prior authorization requests approved after appeal |
4% |
| Average time to decision for standard prior authorizations (days) |
1.4 |
| Median time to decision on standard prior authorizations (days) |
1 |
| Percentage of expedited prior authorization requests that were approved |
97% |
| Percentage of expedited prior authorization requests that were denied |
3% |
| Average time to decision for expedited prior authorizations (hours) |
15 |
| Median time to decision for expedited prior authorizations (hours) |
3 |
| Percentage of total prior authorization requests approved with an extended timeframe |
0% |