Med. necessity/care determination criteria
Priority Health applies clinical criteria using the philosophy that the most appropriate level of care for patients should be the safest and least restrictive possible. The goal of treatment is to restore the patient to an optimal level of functioning and independence. Application of these criteria takes into consideration that fact that individual patients vary in their level of clinical complication, and that the full continuum of clinical services does not exist in all geographic areas. Under circumstances of patient complexity or limited service availability, we will recommend a higher level of care than medically necessary in order to assure safe, effective treatment.
Definition of medical necessity
"Medical necessity" is used to mean care that has been determined to be effective, appropriate and necessary to treat a given patient's disorder.
Determining level of care
Each level of care is indicated as either psychiatric or substance dependence (except for the outpatient level of care, which includes both). Review for level of care determination proceeds in a logical progression to confirm:
- The presence of a properly diagnosed mental health or substance abuse disorder amenable to treatment
- Symptoms of sufficient severity to meet the required criteria for admission
- By accepted medical standards, the illness is expected to improve significantly through medically necessary and appropriate care as it relates to the level of care requested
- Clinical requirements for continuing care at that level
Discharge criteria
Discharge criteria, program content, treatment interventions etc., are not included in the medical necessity, admission and continuing care criteria. This is an attempt to avoid being too prescriptive and preempting clinical discourse. Therefore, determinations for discharge from a given level of care are clear: when the patient no longer appears to meet the required criteria for continuing care at a given level of acuity, discharge to a lower level of care is recommended.
How Priority Health determines criteria
These criteria are reviewed annually by the Behavioral Health Committee, a multidisciplinary group of mental health and substance use disorder treatment providers. It includes fully licensed physicians, psychologists, social workers, and board-certified psychiatrists. Priority Health medical director(s) and the director of behavioral health are voting members of this group.
In December 2009, Priority Health adopted the "Patient Practice Guidelines" from the American Society of Addiction Medicine, ASAM PPC-2R, to guide authorization decision making for patients with substance use disorders. The ASAM PPC-2R is the most widely used and comprehensive national guideline for placement continued stay and discharge of patients with alcohol or other drug problems.
Members come first
Priority Health makes every effort to make utilization decisions that are fair and consistent in order to serve the best interests of the member. That is why Priority Health:
- Will make utilization decisions based only on appropriateness of care and service, as well as existence of coverage
- Will not compensate practitioners or other individuals conducting utilization review for denial of coverage or service
- Will not offer financial incentives or rewards for utilization decision-makers to encourage denial of coverage or service
- Will decide on coverage of new technology after comprehensive research and careful review by our Director of Medical Operations and physician committees
