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 Pennsylvania Department of Drug and Alcohol Programs (DDAP) Guidance for Appropriate Application of ASAM in Pennsylvania’s Substance Use Disorder (SUD) System of Care. For additional information, please refer to 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:
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 CBH Member Services.