MEDICAL NECESSITY CRITERIA
For mental health services, Carelon, in cooperation with its Clinical Advisory Committee, has developed Medical Necessity Criteria (approved by the PA Department of Human Services) that serves as a guide for the delivery of services at all levels of care. For substance use disorder services, Carelon utilizes the American Society of Addiction Medicine Patient Placement Criteria (ASAM Third Edition, 2013) as a guide for the delivery of services at all levels of care.
The ASAM will serve as a guide for both network providers and Carelon Service Management staff for requesting and providing service authorizations.
Carelon may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition.