Medical Necessity Criteria
Medical necessity criteria (MNC) 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.
Behavioral health providers can access program descriptions and MNC for CBH-funded services. The MNC for each service are based on HealthChoices Appendices S and T, American Society of Addiction Medicine (ASAM), or OMHSAS-approved criteria as indicated.
For MNC for substance use levels of care, please reference the pamphlet, An Introduction to The ASAM Criteria for Patients and Families. For additional information, please refer to the Pennsylvania Department of Drug and Alcohol Programs (DDAP) ASAM Transition webpage, as well as The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, Third Edition.
For MNC for mental health levels of care, please reference the links below:
MNC for Adult Mental Health Levels of Care
- 23-Hour Crisis Stabilization (23-Hour Bed)
- Acute Partial Hospitalization Program
- Acute Psychiatric Inpatient Hospitalization
- Adult Certified Peer Specialist (CPS)
- Assertive Community Treatment
- Community Intervention and Stabilization Team (CIST)
- Community Treatment Teams
- Community Treatment Team – Clinically Supported Living
- Crisis Residence
- Electroconvulsive Therapy (ECT)
- Ethanol Testing
- Extended Acute Care (EAC)
- Integrated Behavioral Health in Long-Term Care (IBHLTC)
- Long-Term Structured Residence
- Mental Health Residential
- Mobile Psychiatric Rehabilitation Services (MPRS)
- Non-Hospital Extended Acute Care (EAC)
- One-to-One Staffing
- Private Room Exception
- Psychological Testing
- Residential Treatment Facility for Adults (RTFA)
- Screening for Tricyclic Antidepressants (TCA)
- Sub-Acute Inpatient Programs (SAIP)
- Targeted Case Management (TCM)
MNC for Child/Adolescent Mental Health Levels of Care
- Acute Partial Hospitalization
- Acute Psychiatric Inpatient Hospitalization
- Children’s Crisis Stabilization Unit
- Children’s Interim Response Team
- Children’s Mobile Intervention Services
- Clinical Transition and Stabilization Services (CTSS)
- Community Residential Rehabilitation-Host Home (CRR-Host Home)
- Family-Based Mental Health Services (FBS)
- Functional Family Therapy (FFT)
- Intensive Behavioral Health Services (IBHS) – Individual Services
- Intensive Behavioral Health Services (IBHS) – Group Services
- Intensive Behavioral Health Services (IBHS) – Applied Behavior Analysis (ABA)
- One-to-One Staffing
- Private Room Exception
- Psychological Testing
- Residential Treatment Facility (RTF)
- Screening for Tricyclic Antidepressants (TCA)
- Sub-Acute Inpatient Programs (SAIP)
- Youth Certified Peer Specialist (CPS)
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 the underutilization of benefits.
If you want to have more information about the medical necessity criteria used by CBH when making a decision, please contact CBH Member Services.
