The Department of Vermont Health Access (DVHA) uses evidence-based clinical guidelines from nationally recognized sources during review of our quality and health management programs. The purpose of these developed guidelines is to provide clinical guidance to help facilitate and assure quality, effective treatment and interventions for Vermont Medicaid members. DVHA updates clinical guidelines on a regular basis and accounts for significant changes in standards of care.
Clinical guidelines should not be considered as the only resource and are not intended to replace the professional judgment of providers. Guidelines may not apply to every member or clinical situation and some divergence from guidelines is expected. Further, guidelines do not determine insurance coverage of health care services or products. Coverage decisions are based on member eligibility and determination of medical necessity.
As always, clear documentation of the clinical rational and medical necessity for a treatment plan is expected. Minimum documentation requirements can be accessed in the Billing Manuals here: Manuals | Department of Vermont Health Access.
DVHA has clinical criteria for coverage of specific services, and they can be found on the DVHA Clinical Criteria page.
- ABA Clinical Practice Guidelines
- Asthma Clinical Practice Guidelines
- Cardiovascular Disease Guidelines
- Depression Clinical Practice Guidelines
- Developmental Screening Guidelines
- Diabetes Clinical Practice Guidelines
- Re/habilitation Physical and Occupational Therapy and Speech Language Pathology Guidelines
- Substance Use Disorder Office Based Opioid Treatment Guidelines
- Transcranial Magnetic Stimulation Clinical Practice Guidelines