Medical Necessity Criteria
Help Us Improve
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, and fax, mail, or email it to the address on the form. Or write us a letter. Either way, your feedback will be considered during our annual Medical Necessity Criteria review.
On Dec. 1, 2016, Magellan began the transition to use MCG Care Guidelines, along with our proprietary clinical criteria, Magellan Healthcare Guidelines, as the primary decision support tools for our Utilization Management Program. Collectively, they are known as the Magellan Care Guidelines.
All plans use the 2017 Magellan Care Guidelines unless noted in the State/Client-Specific Criteria section below.
All guidelines meet federal, state, industry accreditation, and customer contract requirements. They are based on sound scientific evidence for recognized settings of behavioral health services and are designed to decide the medical necessity and clinical appropriateness of services.
Current Medical Necessity Criteria
2017 Magellan Care Guidelines include:
- Magellan Healthcare Guidelines – these are publicly available at the link above
- MCG Care Guidelines – these are proprietary; to view a copy of the MCG Care Guidelines, contact Magellan at the number on the member's benefit card, and a representative will send you a copy or grant you special online access
Archived Medical Necessity Criteria
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. For more information on the use of the below criteria, contact the medical director at your Magellan Care Management Center.
Maryland Fully Insured Regulated Accounts – use Outpatient Applied Behavior Analysis - Fully Insured Maryland Regulated Accounts guidelines.
Maryland Residential Crisis Services – criteria for residential crisis services for adults, adolescents and children whose insurance is written out of the state of Maryland.
North Carolina Definition of Medically Necessary Services or Supplies – for North Carolina providers, this definition replaces Magellan’s definition in Magellan’s Medical Necessity Criteria and provider agreements.
Pennsylvania HealthChoices – criteria for providers serving members of the HealthChoices Program in Pennsylvania can be found within the Pennsylvania HealthChoices provider handbook supplement.
Transcranial Magnetic Stimulation (TMS) Privileging Criteria (PDF) – providers must meet the specified requirements for treatment of Major Depression using Transcranial Magnetic Stimulation (TMS).
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.