What Are Milliman Criteria Guidelines?

Milliman criteria or care guidelines are a set of health care standards and clinical practices that help determine the preferred course of treatment in medical situations. The standards appear in the Milliman Care Guidleines and encompass extensive research and analysis of treatment results that health care practitioners submit.

Editors gather the input of thousands of doctors, nurses and other providers to develop evidence-based guidelines and criteria. Milliman packages these standards as guidelines and software for licensing to hospitals, insurers and other health care providers and updates them annually. The Milliman Care Guidelines determine how a majority of Americans gets their health care as of 2015.

By identifying and implementing best practices and minimizing deviations, practitioners are able to improve efficiency and the overall quality of care they provide. The guidelines also determine medical necessity, document treatments and observable results, educate providers and patients, and establish goals.

The guidelines currently address ambulatory care, inpatient and surgical care, general recovery care, home care, and recovery facility care, as well as behavioral health care, chronic care, and patient information. For example, the inpatient and surgical care guidelines provide criteria, goals, care pathways and other decision-support tools to determine and evaluate decisions to admit and discharge patients, develop a treatment plan, and establish recovery goals and follow-up care. The Patient Information tools provide handouts to patients that explain their treatment, prepare them for surgery, and outline postoperative procedures.