Clinical Criteria

A medical guideline, also called clinical criteria, is a document with the aim of guiding medical decisions regarding diagnosis, management, and treatment in specific areas of health care. Below you will find information about Capital Health Plan's clinical criteria for our Commercial and Medicare plans. 

Commercial Criteria

All non-Medicare plans, also known as Commercial plans, require that you follow certain developed criteria that require prior authorization. You can read "What's New" regarding the latest updates for Florida Blue coverage guidelines by clicking here.

Additionally, Capital Health Plan has a partnership with AIM Specialty Health (AIM) to provide utilization management for our Radiation Oncology Program to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.

Medicare Criteria

All Medicare plans require that you follow certain developed criteria that require prior authorization. You can read "What's New" regarding the latest updates for Original Medicare coverage guidelines for National Coverage Decisions (NCD) and Local Coverage Decisions (LCD) by clicking here.

Additionally, Capital Health Plan has a partnership with AIM Specialty Health (AIM) to provide utilization management for our Radiation Oncology Program to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.

Radiation Oncology Program

Capital Health Plan has a partnership with AIM Specialty Health (AIM) to provide utilization management for our Radiation Oncology Program to ensure clinically appropriate quality of care and to manage the increasing utilization of these services. View more information about this program here.