Medical Necessity Criteria

Beacon’s medical necessity criteria, also known as clinical criteria, are based on nationally recognized resources, including but not limited to, those publicly disseminated by the American Medical Association (AMA), American Psychiatric Association (APA) and American Academy of Child and Adolescent Psychiatry (AACAP), Substance Abuse and Mental Health Services Administration (SAMHSA), the American Society of Addiction Medicine (ASAM), MCG (formerly known as Milliman Care Guidelines), and the Center for Medicaid and Medicare (CMS). For management of substance use services, Beacon uses ASAM criteria.

Medical necessity criteria may vary according to individual state and/or contractual requirements and member benefit coverage. Use of other substance use criteria other than ASAM is required in some jurisdictions.

    1. INTRODUCTION
      • 1.10 Clinical Philosophy
      • 1.20 Determining Medical Necessity
      • 1.30 Determining the Appropriate Level of Care
      • 1.40 Evaluating Necessity for Continued Care
      • 1.50 Discharge Criteria
      • 1.60 Clinical Criteria Development
      • 1.70 Account Specific Variations
    2. MENTAL HEALTH FACILITIES AND PROGRAMS
    3. MENTAL HEALTH FACILITIES AND PROGRAMS
    4. SUBSTANCE USE PROGRAMS: ADULT AND ADOLESCENT
      Beacon Health Options uses the American Society of Addiction Medicine, Inc. (ASAM) Patient Placement Criteria to make authorization determinations for substance use services. For more information about a determination for substance use services, please read Introduction to The ASAM Criteria for Patients and Families.

Medical Necessity Criteria: 2018 Reference List