Medical Necessity Criteria

Beacon’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’s Corporate Medical Management Committee (CMMC) adopts, reviews, revises and approves Medical Necessity Criteria per client and regulatory requirements.

Medical Necessity Criteria varies according to state and/or contractual requirements and member benefit coverage. To determine the proper Medical Necessity Criteria, use the following as a guide:

  1. For all Medicare members, first 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 and for all non-Medicare members, identify relevant custom Medical Necessity Criteria.
  3. If no custom criteria exists for the applicable level of care and the treatment is substance use related, the American Society of Addiction Medicine (ASAM) criteria would be appropriate.
    * Exception: Substance Use Lab Testing Criteria is in InterQual® Behavioral Health Criteria.
  4. If the level of care is not substance use related, Change Healthcare’s Interqual® Behavioral Health Criteria would be appropriate.
  5. If 1-4 above are not met, Beacon’s National Medical Necessity Criteria would be appropriate.

Historical criteria are provided for informational purposes only and are not subject to the same review process/timeframes. Medical Necessity Criteria is available online via hyperlinks whenever possible and is available upon request.

The following are Beacon’s Medical Necessity Criteria:

  1. Centers for Medicare and Medicaid (CMS) Criteria
    • The Medicare Coverage Database (MCD) to contains all National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).
    • For all Medicare members, first identify relevant NCD or LCD Criteria.
  2. Change Healthcare’s InterQual ® Behavioral Health Criteria
    • Effective September 21, 2019, Beacon will begin using Change Healthcare’s InterQual® Behavioral Health Medical Necessity Criteria, unless otherwise noted the Custom Criteria.
  3. American Society of Addiction Medicine (ASAM) Criteria
    • The American Society of Addiction Medicine (ASAM) Criteria focuses on substance use treatment.
    • For information about The ASAM Criteria, see the Introduction to The ASAM Criteria for Patients and Families 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 (e.g., LOCADTR in New York) 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.
  4. Custom Criteria
  5. Beacon’s National Medical Necessity Criteria
    1. Introduction to Beacon’s National Medical Necessity Criteria
      Including information such as Clinical Philosophy, Determining Medical Necessity, Determining the Appropriate Level of Care, Evaluating Necessity for Continued Care, Discharge Criteria, Clinical Criteria Development, and Account Specific Variations.
    2. Emergency/Crisis Services
    3. Inpatient Services
    4. Residential Treatment Services
    5. Structured Day Treatment Services
    6. Case Management Services
    7. Outpatient Services
    8. Other Criteria
    9. Medical Necessity Criteria: Reference List