Medical Necessity Criteria
Medical Necessity Criteria -- 2014 (effective January 1, 2014) (PDF 706K)
Medical Necessity Criteria -- 2013 (effective January 1, 2013) (PDF 725K)
Medical Necessity Criteria -- 2012 (effective January 1, 2012) (PDF 720K)
State-Specific and Client Requirements
Specific state laws and client requirements may require modified medical necessity criteria. If you have members in care under any of the benefit plans, in any of the states, or employed by any of the employers requiring modified criteria, please refer to the appropriate medical necessity criteria below.American Society of Addiction Medicine (ASAM) - substance abuse criteria for:
- Independence Blue Cross and its affiliates' covered members in Pennsylvania, New Jersey, and Delaware
- Capital Blue Cross covered members
- Pennsylvania HealthChoices' child and adolescent members
- Other customers throughout the country
Applied Behavior Analysis Medical Necessity Criteria (PDF 120K) - Magellan Covers applied behavior analysis (ABA) when state-mandated or when ABA is specifically included in a customer's benefit plan. View a list of current plans with coverage. (PDF 20K)
Blue Cross Blue Shield of Michigan -- Medical Necessity may be accessed by logging in to the BCBSM provider portal on web DENIS. Once logged in to web DENIS,
- Click on BCBSM Provider Publications and Resources
- Click on Newsletters and Resources
- Click on Clinical Criteria and Resources
- Click on 2014 updated Magellan Behavioral Health Medical Necessity Criteria under Resources
Blue Shield of California -- Human Affairs International of California (HAI-CA) reviews and determines medical necessity for Blue Shield of California members using BSC-specific Behavioral Health Medical Necessity Criteria. In addition, HAI-CA has adopted criteria for neuropsychological testing.
California Medical Necessity Criteria - The Magellan California subsidiaries, Human Affairs International of California and Magellan Health Services of California, Inc. -- Employer Services, have adopted Magellan's Medical Necessity Criteria (located at the top of this page).
Capital BlueCross (CBC) and Independence Blue Cross (IBC) -- criteria for the following outpatient covered services for CBC and IBC plans.
- Applied Behavior Analysis (PDF 85K)
- Behavior Specialist Consultation (PDF 77K)
- Mobile Therapy (PDF 82K)
- Therapeutic Staff Support (PDF 72K)
- Partial Hospitalization Program (PDF 128K)
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) Medical Necessity Criteria (PDF 756K) -- criteria to guide providers to the most appropriate level of care for CHAMPVA members.
Florida Medical Necessity Criteria – criteria that adhere to Florida regulatory and agency contractual requirement for Magellan Behavioral Health of Florida, Inc.
- Prepaid Mental Health Plan (PMHP): Areas 2 and 4, Area 9, and Area 11
- Community Based Care Partnership: Child Welfare
Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) - Magellan reviews and determines medical necessity using the Magellan Behavioral Health Medical Necessity Criteria. In addition, we have implemented criteria for methadone maintenance and ambulatory laboratory screening for substance use disorders specifically for use with BCBSNJ members.
Maryland Medical Necessity Criteria for Residential Crisis Services (PDF 29K) – criteria for residential crisis services for adults, adolescents and children whose insurance is written out of the state of Maryland.
Nebraska Medicaid Managed Care Program (NMMCP) and Nebraska Medical Assistance Program (NMAP) - you can find medical necessity criteria for serving these members in the appendix of Magellan's Provider Handbook Supplement for NMMCP and NMAP.
North Carolina Definition of Medically Necessary Services or Supplies (PDF 29K) – for North Carolina providers, this definition replaces Magellan’s definition in Magellan’s Medical Necessity Criteria and provider agreements.
Pennsylvania HealthChoices – information on medical necessity criteria for providers serving members of the HealthChoices Program in Pennsylvania can be found in the Pennsylvania HealthChoices provider handbook supplement and its applicable appendices. These include the Pennsylvania Department of Public Welfare criteria, Magellan supplemental criteria, the Pennsylvania Client Placement Criteria for Adults (PCPC), and the American Society of Addiction Medicine (ASAM) criteria.
Transcranial Magnetic Stimulation (TMS) Privileging Criteria (PDF 93K) -- criteria for authorization of TMS to treat major depressive disorder
State of Texas Standards for Reasonable Cost Control and Utilization Review for Chemical Dependency Treatment–criteria for all alcohol and substance abuse treatment services provided to members whose benefit plans are written in Texas.
Yale University (PDF 603K)-- Medical necessity criteria for members enrolled with Yale Health Plan.
For more information on the use of the above criteria, please contact the medical director at your Magellan Care Management Center.
Do you have a comment or suggestion on how we can improve our Medical Necessity Criteria? We want to hear from you. Please print and complete our comment form (PDF 29K), and fax, mail, or e-mail it to the address on the form. Or simply write us a letter. Either way, your feedback will be considered during our annual Medical Necessity Criteria review.
Adobe Reader is required to view PDF files.