Medical Necessity Criteria

SECTION TITLE DATE REVISED
1. 000 INTRODUCTION
1.100 Individuals Served by Carelon’s Public Sector Programs
1.200 Clinical Criteria Manual Development
2. 000 CLINICAL CRITERIA
2.000 Clinical Criteria Concepts
2.100 Assessment and Referral Risk-Rating Scale
2.200 Determining Clinical Necessity
2.300 Determining Appropriate Level of Care
2.301 Residential Treatment Facility – Adult
2.400 Evaluating Clinical Necessity for Continued Care
2.500 Discharge Criteria
2.503 Assertive Community Treatment (ACT) Criteria
3. 000 SERVICE MANAGEMENT
3.100 Overview
3.200 Outcomes
3.300 Individualized Service Plans
3.400 Coordination of Care
3.500 Discharge and Transition Plans
4.000 IN-PLAN ADULT MENTAL HEALTH SERVICES
4.100 Emergency/Crisis Services
4.101 Telephone Crisis Service
4.102 Walk-in Crisis Service
4.103 Mobile Crisis Service
4.200 Inpatient Programs
4.201 Acute Inpatient Mental Health
4.202 Adult Inpatient Extended Acute Care Criteria
4.300 Outpatient Treatment
4.300 Outpatient Psychotherapy Criteria
4.301 Outpatient Therapy
4.302 Psychological Testing
4.303 Family Therapy
4.304 Partial Hospitalization
4.306 Medication Management
4.307 Group Psychotherapy
4.308 Diagnostic Evaluation
4.309 Intensive Outpatient Programs (IOP) Adults
4.400 Case Management
4.401- 4.402 Intensive Case Management for Adults/Resource Coordination for Adults
4.500 Clozapine Support Services
4.501 Clozapine (Clozaril Management)
4.600 Electroconvulsive Therapy (ECT)
4.601 Electroconvulsive Therapy (ECT)
5.100 AMERICAN SOCIETY OF ADDICTION MEDICINE – THIRD EDITION, 2013
ASAM Crosswalk with Pennsylvania’s System of Care
ASAM Crosswalk
ASAM Level 1
Outpatient (OP) Services
ASAM Level 2.1
Intensive Outpatient (IOP) Services
ASAM Level 2.5
Partial Hospitalization (PHP) Services
ASAM Level 3.1
Clinically-Managed Low Intensity Residential Services, i.e., Halfway House (HWH)
ASAM Level 3.5
Clinically Managed High Intensity Residential Services
ASAM Level 3.7
Medically Monitored Inpatient Withdrawal Management – 3.7 WM
Medically Monitored Intensive Inpatient Services
ASAM Level 4
Medically Managed Intensive Inpatient Withdrawal Management – 4 WM
Medically Managed Intensive Inpatient Services – 4.0
6.000 IN PLAN CHILD/ADOLESCENT MENTAL HEALTH SERVICES
6.100 Emergency / Crisis Services
6.101 Telephone Crisis Service
6.102 Walk In Crisis Service
6.103 Mobile Crisis Service
6.200 Inpatient Programs
6.201 Acute Inpatient Mental Health
6.202 Subacute Inpatient Mental Health
6.300 Non-Hospital, Out-of-Home Placement
6.301 Residential Treatment (JCAHO and non-JCAHO)
6.302 Community Residential Rehabilitation Host Home
6.400 Outpatient Treatment
6.400 Outpatient Psychotherapy Criteria
6.401 Outpatient Therapy
6.402 Partial Hospitalization
6.403 Psychological Testing
6.404 Group Psychotherapy
6.405 Family Therapy
6.406 Medication Management
6.407 Diagnostic Evaluation
6.408 Intensive Outpatient Program (IOP) Child / Adolescent)
6.500 Case Management Services
6.502- 6.503 Resource Coordination & Intensive Case Management (Children / Adolescent)
6.600 Family Based Mental Health Services
6.601 Family Based Mental Health Services
7.000 IN PLAN ADOLESCENT DRUG AND ALCOHOL SERVICES
For all levels of adolescent Substance Use Disorder services, please follow the American Society of Addiction Medicine, Third Edition, 2013 Treatment Criteria: https://www.asam.org
9.000 SUPPLEMENTAL ADULT MENTAL HEALTH SERVICES
9.100 Residential Programs
9.103 Crisis Residential Services
9.104 Long Term Structured Residential Treatment Centers
9.200 Outpatient Treatment
9.201 Psychiatric Rehabilitation Program – Admission Requirements
9.202 Psychiatric Rehabilitation Program – Continued Stay Requirements
9.203 Psychiatric Rehabilitation Program – Discharge Requirements
10.000 SUPPLEMENTAL ADULT DRUG AND ALCOHOL SERVICES
10.101 Drug and Alcohol Intensive Case Management (Formerly, Targeted Case Management) For Adults
10.102 Drug and Alcohol Assessment / Level of Care determination
11.000 SUPPLEMENTAL CHILD/ADOLESCENT MENTAL HEALTH SERVICES
11.600 Crisis Residential Service
12.000 SUPPLEMENTAL CHILD/ADOLESCENT DRUG AND ALCOHOL SERVICES
12.101 Drug and Alcohol Intensive Case Management (Formerly, Targeted Case Management) For Children/Adolescents
13.000 OTHER ADULT MENTAL HEALTH SERVICES
13.100 Emergency/Crisis Services
13.101 Medical Mobile Crisis Team Service
13.102 23-Hour Assessment and Crisis Stabilization
13.103 23-Hour Crisis Observation, Evaluation, Holding, and Stabilization (Adult)
13.104 Non-Hospital Observation and Supervision
13.200 Outpatient Treatment
13.201 Acute Partial Hospitalization
14.000 OTHER CHILD AND ADOLESCENT MENTAL HEALTH SERVICES
14.100 Emergency/Crisis Services
14.101 23-Hour Crisis Observation, Evaluation, Holding, and Stabilization (Child / Adolescent)
14.102 Non-Hospital Observation and Supervision
14.103 Acute Partial Hospitalization
14.104 Medical Mobile Crisis Team Service
14.105 Multisystemic Therapy (MST)
14.106 Functional Family Therapy (FFT) Service
15.000 APPENDIX T HEALTHCHOICES BEHAVIORAL HEALTH SERVICES
15.101 Guidelines for Mental Health Necessity Criteria (Appendix T)
17.000 INTENSIVE BEHAVIORAL HEALTH SERVICES (IBHS)
17.100 Medical Necessity Guidelines for IBHS Delivered through Individual Services, ABA Services and Group Services – Appendix S(2)
17.101 IBHS Description of Applied Behavior Analysis
17.102 IBHS Description of Individual Services
17.103 IBHS Description of Group Services