---
kind: "section"
citation: "42 C.F.R. § 438.236"
title: "42"
number: "438.236"
heading: "Practice guidelines."
url: "https://uscodex.org/cfr/42/438.236"
---

# §438.236. Practice guidelines.

- (a) **Basic rule.** The State must ensure, through its contracts, that each MCO, PIHP, and PAHP meets the requirements of this section.
- (b) **Adoption of practice guidelines.** Each MCO and, when applicable, each PIHP and PAHP adopts practice guidelines that meet the following requirements:
  - (1) **Are based on valid and reliable clinical evidence or a consensus of providers in the particular field.**
  - (2) **Consider the needs of the MCO's, PIHP's, or PAHP's enrollees.**
  - (3) **Are adopted in consultation with network providers.**
  - (4) **Are reviewed and updated periodically as appropriate.**
- (c) **Dissemination of guidelines.** Each MCO, PIHP, and PAHP disseminates the guidelines to all affected providers and, upon request, to enrollees and potential enrollees.
- (d) **Application of guidelines.** Decisions for utilization management, enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the guidelines.

## Notes

### Amendments

[81 FR 27853, May 6, 2016, as amended at 85 FR 72841, Nov. 13, 2020]

### Source

Source: 81 FR 27853, May 6, 2016, unless otherwise noted.

### Authority

Authority: 42 U.S.C. 1302.

### Source

Source: 67 FR 41095, June 14, 2002, unless otherwise noted.

### Amendments

[81 FR 27853, May 6, 2016, as amended at 85 FR 72841, Nov. 13, 2020]