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Magellan Health

Medical Necessity Criteria

Magellan uses 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.

Effective July 1, 2018, all plans will use the 2018-2019 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. 

Medical Necessity Criteria (effective July 1, 2018)

The 2018-2019 Magellan Care Guidelines (PDF) become effective July 1, 2018, and 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.

Review a summary of changes (PDF) to the 2018-2019 Magellan Care Guidelines.

Archived Medical Necessity Criteria

2017-2018 Magellan Care Guidelines (PDF)

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) 

Blue Shield of California - remains on the 2017-2018 Magellan Care Guidelines (PDF). Check back for date of transition to 2018-2019 Magellan Care Guidelines.
 

Louisiana Coordinated System of Care (CSoC) 

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 at www.MagellanofPA.com.

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 Department of Medical Assistance Service (DMAS)