Clinical Guidelines

Gold Kidney has adopted clinical guidelines from the following organizations to optimize patient care. Using a systematic approach to assessing care options and alternatives leads to more positive healthcare outcomes.

Medical Policies and Guidelines

Clinical Decision-Making Hierarchy

Gold Kidney Health Plan makes medical necessity and coverage determinations for Medicare Advantage members using the following decision-making hierarchy:

Medicare Coverage Criteria

Gold Kidney Health Plan applies applicable Medicare coverage criteria first, including, but not limited to:
Internal Coverage Criteria When Medicare Criteria Are Not Fully Established

When Medicare coverage criteria are not fully established, Gold Kidney Health Plan may use approved internal coverage criteria to support medical necessity determinations. Internal coverage criteria are reviewed and approved through Gold Kidney Health Plan’s Utilization Management governance process and are not applied in a manner that is more restrictive than Traditional Medicare coverage requirements.

Internal coverage criteria are based on current evidence in publicly available, widely used treatment guidelines or clinical literature, such as:
A. Nationally recognized evidence-based guidelines/criteria, in conjunction with the clinical judgement of a qualified health professional, including, as applicable:
- Utilization Management Decision-Support Guidelines (such as MCG® or InterQual®) (Gold Kidney Health Plan is working with MCG to implement electronic access to applicable MCG criteria by June 30, 2027. Until then, practitioners may request criteria by emailing utilization_management@goldkidney.com, calling 844-294-6535, or faxing 866-515-7869. Criteria will be provided promptly and electronically, subject to licensing requirements.)
- KDIGO Guidelines
- HFSA Guideline for Management of Heart Failure
- ACC Guidelines and Clinical Documents Library
- SVS Clinical Practice Guidelines
- National Comprehensive Cancer Network (NCCN) guidelines
and/or
B. ‘In coverage situations where there is no NCD, LCD, or guidance on coverage in original Medicare manuals, an MAO may adopt the coverage policies of other MAOs in its service area’. (Reference: Medicare Managed Care Manual (MMCM) Chapter 4, Section 90.5 Creating New Guidance) — View source

NOTE Federal and state mandates, Medicare requirements, and applicable contract language, including definitions, coverage provisions, and exclusions, may take precedence and must be considered when determining coverage.

Continuity of Care

Gold Kidney Health Plan collaborates with delegated provider organizations, as applicable, to coordinate care and services for members newly enrolled with Gold Kidney Health Plan or transitioning to a new Primary Care Provider (PCP) and/or provider organization. Gold Kidney Health Plan supports continuity of care to help avoid unnecessary disruption in medically necessary services and to ensure safe transition to in-network providers when medically appropriate.

Gold Kidney Health Plan provides a transition period for active courses of treatment in accordance with applicable Medicare Advantage requirements. When medically necessary, or when services are not available in-network, provisions may be made to access or continue care with out-of-network providers.

Continuity of care may be requested for services including, but not limited to:

Outpatient mental health or substance use disorder treatment
Current acute inpatient or skilled nursing facility hospitalization
Chemotherapy, radiation therapy, or nuclear medicine
Complex chronic conditions requiring continued care and ongoing services
Durable medical equipment (e.g. oxygen, hospital bed)
Terminal illness requiring continued care and ongoing services
Previously authorized surgery or procedure scheduled within the applicable transition timeframe

Continuity of care activities may include coordinating services authorized by a previous health plan or previous medical group, including scheduled surgery, specialty appointments, durable medical equipment, and medication coordination needs, including Continuity Rx when applicable. Activities may also include evaluating whether requests meet continuity of care criteria and collaborating with Utilization Management to review and authorize requests as appropriate.

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