Determining Medical Necessity
PCHP uses the following resources to determine medical necessity:
PCHP uses the following clinical elements for determining medical necessity for behavioral health services:
- Assessment of local delivery system and network access
- Co-occurring conditions (SUD, medical, IDD)
- Coordination between BH and medical providers
- Current medications or medication changes
- Current symptoms (e.g., risk to self/others, psychosis, active substance use, relapse risk)
- Current treatment plan
- Diagnosis
- Discharge plan
- Family and social supports
- Functional impairment
- Presenting problem/reason for referral
- Psychosocial situation and home environment
- Response to treatment or barriers to treatment
Request for SUD services may be reviewed using ASAM criteria. Reviews will be largely structured around the 6 Dimensions. Providers will be expected to identify the level of care requested based on ASAM LOCs.
When requesting authorization for court-ordered care, providers must submit a copy of the court order to PCHP. If a court order is not received, PCHP will process the request using appropriate medical necessity criteria.