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 Aug. 27, 2022 all plans use the 2022-2023 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 Aug. 27, 2022)

The 2022-2023 Magellan Care Guidelines (PDF) include:

• Magellan Healthcare Guidelines -- These are publicly available at the link above.
• MCG Care Guidelines -- These guidelines are proprietary to MCG Health; to view a copy of a guideline associated with a member’s clinical review, 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 2022-2023 Magellan Care Guidelines.

Archived Medical Necessity Criteria

2021-2022 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) and An Introduction to The ASAM Criteria for Patients and Families (PDF)

Licensee's use and interpretation of the American Society of Addiction Medicine’s ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits.

California

• All plans - 2022-2023 California Review Criteria / Guidelines Grid (PDF) in compliance with Senate Bill 855 
• Blue Shield of California - In addition to 2022-2023 Magellan Care Guidelines and 2022-2023 California Review Criteria / Guidelines Grid (PDF), the following apply for BSC members: Blue Shield of California Medical Policy for Behavioral Health Treatment for Autism Spectrum Disorders (PDF), Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders (PDF) and Neuropsychological Testing (PDF).

Louisiana

• Louisiana Coordinated System of Care (CSoC) (PDF) 

New Mexico

• New Mexico Prior Authorization Requirements and Clinical Criteria

North Carolina

• 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

• Pennsylvania HealthChoices – criteria for providers serving members of the HealthChoices Program in Pennsylvania can be found at www.MagellanofPA.com.

Texas

• Blue Cross and Blue Shield of Texas (under Health Care Service Corporation) – The 2020-2021 Magellan Care Guidelines apply with the following guideline modified for non-Medicare BCBSTX plans that cover TMS: Transcranial Magnetic Stimulation (PDF).
• The Texas Medicaid Provider Procedures Manual (PDF) was updated with the Autism Services Policy language, effective Feb. 1, 2022, see page 18. Magellan follows this policy from the Texas Health and Human Services Commission when making determinations for STAR and STAR Kids members.

Virginia

• Virginia Department of Medical Assistance Service (DMAS) 

Privileging criteria

Transcranial Magnetic Stimulation (TMS) Privileging Criteria (PDF) – providers must meet the specified requirements for treatment of Major Depression using Transcranial Magnetic Stimulation (TMS).