Medical necessity criteria

Below is a general outline that our care managers will follow when reviewing; however depending on the specifics, the care manager may ask for additional information. In some instances, initial authorizations occur via our fast-certification process. This allows us to authorize days upfront with limited clinical information. For Concurrent Reviews, Care Managers will then need to obtain all clinical information that was not given during the initial review.

DSM Diagnosis Information

• Include any Clinical Disorders, Personality Disorders, Intellectual Disability, or General Medical Conditions

Clinical Presentation

• Reason for admission (MH & SA HX, SU issues, mental health status, stressors)
• Clinical factors that support your requested level of care
• Medications: Types, dosage, frequency, titration plan and who prescribed
• Additional comments and/or concerns about medication use as it relates to the current diagnosis
• Family/support sessions (when, who, what or why not)
• Barriers to discharge

Treatment Planning

• Identify specific and measurable treatment goals and interventions
• Family sessions
• If in a Partial Program, describe how patient is using the skills outside of treatment hours

Discharge Planning

• Identify discharge plan
• 7-day follow up appointments
• Identify any barriers to follow-up
• Has the outpatient provider been notified of the admission?
• Please provide the discharge information during last review or if no further authorization is needed, you may leave the information on the designated staff’s voicemail.