Clinical Criteria

DVHA staff utilizes clinical criteria for making Utilization Review (UR) decisions that are objective and based on sound medical evidence. Adopted criteria include the following:

  • Change HealthCare InterQual® Guidelines; 
  • DVHA Clinical Guidelines; and
  • Vermont State Medicaid Rules.

Change Healthcare InterQual® Guidelines are available to providers on the Vermont Medicaid secure provider web portal. After log-in, look for the link Change Healthcare Smart Sheets on the left window. InterQual® Guidelines are updated annually.

Visit the Vermont Medicaid Fee Schedule for the codes that require prior authorization. Excess quantity may require prior authorization.

 

ACO Prior Authorizations

Durable Medical Equipment

Imaging

Imminent Harm Procedure Codes Requiring Prior Authorization

Laboratory and Radiology Criteria

Procedure Criteria

Therapy Guidelines

Department of Vermont Health Access

280 State Drive
Waterbury, Vermont 05671-1010
Phone: 802-879-5900
Fax: 802-241-0260

Department Contact List for customer service, program telephone and fax numbers, and staff email

Hours of Operation: Monday-Friday (Excluding Holidays) 7:45am - 4:30pm

Public Record Requests
Kelly Provost
DVHA Public Records Officer
AHS.DVHALegal@Vermont.gov
Visit the Agency of Administration site for the Public Records Database

Report Medicaid Fraud, Waste, and Abuse