Medical necessity criteria

Our medical necessity criteria, also known as clinical criteria, are reviewed and updated at least annually to ensure they reflect the latest developments in serving individuals with behavioral health diagnoses.

Carelon Behavioral Health’s Corporate Quality and Medical Management Committee adopts, reviews, revises, and approves medical necessity criteria per client and regulatory requirements.

If needed, complete a medical necessity criteria application for InterQual. To access the InterQual criteria, log-in here or request user credential.

Medical necessity criteria step-by-step guide

Medical necessity criteria vary according to state and/or contractual requirements and member benefit coverage. To determine the proper medical necessity criteria, perform the following:

1. For all Medicare members, identify relevant Centers for Medicare and Medicaid (CMS) national coverage determinations (NCD) or local coverage determinations (LCD) criteria.

2. If no CMS criteria exist for Medicare members and for all non-Medicare members, identify relevant custom medical necessity criteria.

3. If no custom criteria exist for the applicable level of care and the treatment is substance use related, the American Society of Addiction Medicine (ASAM) criteria would be appropriate. (Exceptions: Substance Use Lab Testing Criteria is in InterQual® Behavioral Health Criteria. LOCADTR 3.0 for all Substance use related request in New York State.)

4. If the level of care is not substance use related, Change Healthcare’s InterQual® Behavioral Health Criteria would be appropriate.

5. If steps 1 to 4 are not met, Carelon Behavioral Health’s National Medical Necessity Criteria would be appropriate.

Medical necessity criteria

Historical criteria are provided for informational purposes only and are not subject to the same review process/timeframes. Medical necessity criteria are available online via hyperlinks whenever possible and are available upon request.

The following are Carelon Behavioral Health’s medical necessity criteria:

Centers for Medicare and Medicaid (CMS) Criteria

The Medicare Coverage Database (MCD) contains all national coverage determinations (NCDs) and local coverage determinations (LCDs).

For all Medicare members, first identify relevant NCD or LCD Criteria.

Change Healthcare InterQual® Behavioral Health Criteria

Carelon Behavioral Health utilizes Change Healthcare’s InterQual Behavioral Health Medical Necessity Criteria for mental health levels of care and substance use laboratory testing, unless otherwise noted that custom criteria should be used.

American Society of Addiction Medicine (ASAM) Criteria

The American Society of Addiction Medicine (ASAM) criteria focuses on substance use treatment.

For information about The ASAM Criteria, see An Introduction to The ASAM Criteria for Patients and Families . (Copyright 2015 by the American Society of Addiction Medicine. Reprinted with permission. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM.)

Unless custom criteria exist (for example, LOCADTR in New York) or for substance use laboratory testing (found in InterQual Behavioral Health Criteria), ASAM criteria are used for substance use treatment services.

Custom Criteria

State-Specific Medical Necessity

MCG Health Behavioral Health Care criteria (formerly known as Milliman Care Guidelines) are used for some plans.

 

State-Specific Criteria

New York

In adherence with State of New York Guiding Principles for the Review and Approval of Clinical Review Criteria for Mental Health Services, Carelon Behavioral Health may only use one level of care criteria for all New York business. Accordingly, only InterQual continued stay criteria will be used for review of mental health services in New York, regardless of where the member is in the treatment episode.

6.103 Psychiatric Disability Determination Criteria for Dependents (Empire) 

 

Texas

Carelon Behavioral Health Utilization and Review Notification Timeframes 

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