Medical necessity criteria are a group of medical criteria used to determine if your situation meets the need for a type of service. CBH uses medical necessity criteria when making a decision about services that require prior authorization. See the covered services section on the website or in the member handbook for information about services that require prior authorization.
CBH authorization decisions are made based on eligibility criteria and medical necessity criteria as approved by the Commonwealth of Pennsylvania. CBH does not reward or provide any form of incentive to physicians for denying services. CBH does not reward or provide any form of incentive to clinical management staff to make decisions that result in underutilization of benefits.
If you want to have more information about the medical necessity criteria used by CBH when making a decision, please contact member services at 1-888-545-2600.