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Medical Necessity Criteria

Alert: Update to Medical Necessity Criteria. See below for details.

In addition to Magellan’s proprietary clinical criteria (Magellan Healthcare Guidelines), Magellan soon will use the 20th edition Milliman Care Guidelines as the primary decision support tool for our Utilization Management Program. Collectively, they will be known as the Magellan Care Guidelines.

The Magellan Care Guidelines include a combination of Milliman Care Guidelines for behavioral health acute services as well as proprietary clinical criteria that Magellan has developed and maintains for specialty behavioral outpatient services. Magellan also uses ASAM criteria for management of substance use services where required by state or customer contract.

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.

Note that criteria for some levels of care, plans and states will differ. Sign in securely to this website for details by plan. After signing in, click “Medical Necessity Criteria” from the Clinical Guidelines box, then scroll down to the MNC Transition by Plan grid

Until the Magellan Care Guidelines are effective, plans will continue to use the current Magellan Medical Necessity Criteria or their state/client-specific criteria list below.

Current Magellan Medical Necessity Criteria

Archived Medical Necessity Criteria

State/Client-Specific 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.

American Society of Addiction Medicine (ASAM) 

Applied Behavior Analysis – for Fully Insured Maryland Regulated Accounts, use Outpatient Applied Behavior Analysis - Fully Insured Maryland Regulated Accounts guidelines (PDF).

AvMed – Magellan Care Guidelines are used as the primary decision support tool for the AvMed UM program. 

Blue Shield of California – criteria for providers serving Blue Shield of California members can be found in the California Medical Necessity Criteria with the exception of specific Neuropsych Testing Medical Necessity Guidelines.

California Medical Necessity Criteria – criteria for providers serving members in California.

Geisinger Health System – Magellan Care Guidelines are used as the primary decision support tool for the Geisinger UM program.

Louisiana Coordinated System of Care (CSoC) – criteria for the Louisiana CSoC. 

Maryland Residential Crisis Services – 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) – criteria for serving these members is in the appendix of Magellan's Provider Handbook Supplement for NMMCP and NMAP.

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 in the Pennsylvania HealthChoices provider handbook supplement and its applicable appendices.

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.

Virginia DMAS – Virginia Department of Medical Assistance Services (DMAS) criteria.

Yale University (PDF) – criteria for members enrolled with Yale Health Plan.