Medical Necessity Criteria

Beacon 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. Beacon 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 would be appropriate.
  3. For behavioral health services, custom criteria is often state or plan/contract specific:
    • California Commercial Plans utilize LOCUS/CALOCUS/ECSII and WPATH Standards of Care.
      * Exception: InterQual® Behavioral Health Criteria is utilized for ABA services as there are no non-profit criteria currently available.
    • County Medi-Cal Plans: Title 9 of the California Code of Regulations
      * Exception: InterQual® Behavioral Health Criteria is utilized for Neuropsychological and Psychological Testing requests.
  4. For substance use related services, Beacon of California uses the American Society of Addiction Medicine (ASAM) criteria for all lines of business.
    * Exception: InterQual’s® Behavioral Health Criteria for Substance Use Lab Testing is used for Medicare membership.
  5. If the applicable level of care is not found within the criteria above or 1-4 are not met, Beacon of California’s Medical Necessity Criteria would be appropriate to use for non-Commercial plans.

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

The following are criteria sets Beacon 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. 
  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
    • Effective September 21, 2019, Beacon of California began using Change Healthcare’s InterQual® Behavioral Health Medical Necessity Criteria, unless there is an otherwise noted Custom Criteria set.
  5. Beacon 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:

WPATH:

Beacon 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 Beacon 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. Beacon 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.