Wednesday, January 16, 2019       


  Medical Necessity Criteria  

In order to promote consistent utilization management decisions, all utilization and care management staff and physician reviewers use MHNet's Medical Necessity Criteria unless different criteria are required for a specific account.

These medical necessity criteria are not intended to be construed or to serve as a standard of treatment. Standards of treatment are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns evolve. These criteria should be considered guidelines only. Adherence to them will not ensure a successful outcome in every case. The behavioral health professional, in light of the clinical data presented by the member, must make the ultimate judgment regarding a particular location of care or treatment modality.

Nor are these medical necessity criteria intended to replace sound clinical judgment or internal clinical guidance. When applying the criteria to an individual, case managers and medical directors must consider such factors as:
• Age of the member
• Presence of co-morbidities
• Complications
• The progress of treatment
• The psychosocial situation
• The home environment, when applicable

Case managers and medical directors must also consider the characteristics of the local delivery system that are available for the member, such as:
• Availability of alternative levels of care
• MHNet's or the health plan's coverage of benefits for alternative levels of care
• Ability of local providers to provide all recommended services within the anticipated length of stay

View MHNet's Medical Necessity Criteria in Adobe Acrobat

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