Medical Necessity Criteria

Magellan is committed to the philosophy of promoting treatment at the most appropriate, least-restrictive level of care needed to effectively meet an individual’s biopsychosocial needs. We see the continuum of care as a fluid treatment pathway where individuals may enter treatment at any level and be moved to more or less-intensive settings or levels of care as their changing clinical needs dictate. At any level of care, such treatment is individualized, active, and takes into consideration the individual’s stage of readiness to change and readiness to participate in treatment.

• The Pennsylvania Department of Human Services publishes and maintains behavioral health “Medical Necessity Criteria” for the Pennsylvania HealthChoices program: HEALTHCHOICES BEHAVIORAL HEALTH SERVICES GUIDELINES for MENTAL HEALTH MEDICAL NECESSITY CRITERIA
  • Go to page 197 for Appendix S (MNC for ABA and IBHS)
  • Go to page 207 for Appendix T (MNC for all other services)
• For levels of care not included in the DHS criteria, Magellan has created supplemental Medical Necessity Criteria.
• The Pennsylvania Department of Human Services requires all substance use disorder placement, continued stay, and discharge be conducted in accordance with the most recent version of the American Society of Addiction Medicine (ASAM) criteria.
• Due to ASAM licensure restrictions, Magellan is unable to post the ASAM criteria on its website.

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