Medical Necessity Criteria

Carelon Behavioral Health of California’s Medical Necessity Criteria (MNC), also known as clinical criteria, are reviewed and updated at least annually to ensure that they reflect the latest developments in serving individuals with behavioral health diagnoses. Carelon Behavioral Health of California’s Quality Management/ Utilization Management/ Case Management Committee (QMUMCM) adopts, reviews, revises and approves Medical Necessity Criteria per client and regulatory requirements.

Medical Necessity Criteria may vary according to individual contractual obligations, state/federal requirements and member benefit coverage. To determine the proper Medical Necessity Criteria, use the following as a guide based on plan type and type of service being requested:

  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 exists for Medicare members, Change Healthcare’s Interqual® Behavioral Health Criteria or MCG would be appropriate.
    * Exceptions if criteria sets not found in 1 or 2 above:
    • Either Carelon Behavioral Health of California’s Medical Necessity Criteria or relevant Elevance Clinical UM Guidelines may be appropriate to use.
  3. For behavioral health services, custom criteria is often state or plan/contract specific: 
    • California Commercial Plans utilize LOCUS,CALOCUS-CASII, or ECSII criteria.
      * Exceptions for Commercial plans:
      • InterQual® Behavioral Health Criteria or Elevance Clinical UM Guidelines are utilized for Behavioral Health Treatment (BHT) services.
      • MCG may be used for Transcranial Magnetic Stimulation (TMS) services
    • California Medi-Cal Plans utilize:
      • Specialty Mental Health Services (SMHS): Title 9 California Code of Regulations
      • Non-Specialty Mental Health Services (NSMHS): The most current guidance provided by the state’s All Plan Letter.
        * Exceptions for Medi-Cal plans:
        • InterQual® Behavioral Health Criteria is utilized for Behavioral Health Treatment (BHT) services.
  4. For substance use related services, Carelon Behavioral Health of California uses the American Society of Addiction Medicine (ASAM) criteria for all lines of business.
    * Exceptions for Medicare membership:
    • InterQual® Behavioral Health Criteria (Substance Use Lab Testing) and NCD criteria (Detoxification and/or Rehabilitation).

Medical Necessity Criteria are available online via hyperlinks whenever possible and are available upon request.

The following are criteria sets Carelon Behavioral Health of California may utilize to make Medical Necessity determinations:

  1. 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.
  2. Custom Criteria
    The Custom Criteria are network- and state-specific Medical Necessity Criteria.
    • California Commercial plans utilize LOCUS/CALOCUS- CASII/ECSII criteria and the WPATH Standards of Care in compliance with SB 855.  Additional information related to these criteria can be found in the Educational Resource section below.
  3. American Society of Addiction Medicine (ASAM) Criteria
    • The American Society of Addiction Medicine (ASAM) Criteria focuses on substance use treatment. 
      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 exists or for Substance Use Lab Testing (which is found in in InterQual® Behavioral Health Criteria), ASAM criteria is the criteria for substance use treatment services.
    • For information about The ASAM Criteria, see the Introduction to The ASAM Criteria for Patients and Families
  4. Change Healthcare’s InterQual ® Behavioral Health Criteria
    • Unless there is an otherwise noted Custom Criteria set, Carelon Behavioral Health of California uses Change Healthcare’s InterQual® Behavioral Health Medical Necessity Criteria.
  5. Carelon Behavioral Health of California’s proprietary Medical Necessity Criteria

Educational Resources: Below are links to current training resources. For more information, visit these websites:

ASAM:

ECSII:

LOCUS/CALOCUS-CASII:

24-Hour Access

Carelon Behavioral Health of California provides 24-hour access, including, but not limited to, non-contracting hospitals, to obtain timely authorization for medically necessary care, including post-stabilization services. If you need assistance, click here for Carelon Behavioral Health of California’s toll-free contact information.

AFFIRMATIVE STATEMENT

  1. All UM and CM decision making are based only on appropriateness of care and services and existence of coverage. Level of Care Criteria are used as guidelines.
  2. There are no financial incentives to encourage adherence to utilization targets and discourage under-utilization. Financial incentives based on the number of adverse determination or denials of payment made by any individual involved in UM decision making are prohibited.
  3. Carelon Behavioral Health of California does not make decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual based upon the likelihood that the individual will support the denial of benefits.
  4. The prohibition of financial incentives does not apply to financial incentives established between health plans and health plan providers.
  5. Utilization Management staff in no way rewards or incentivizes, either financially or otherwise, practitioners, utilization reviewers, clinical care managers, physician advisers, or other individuals involved in conducting utilization/case management review, for issuing denials of coverage or service, or inappropriately restricting or diverting care including staff that engage in contracting/network management activities that could potentially influence referrals to specific providers/services.