Determining Medical Necessity
PCHP uses the following criteria resources for determining Medical Necessity:
- Texas Medicaid Provider Procedures Manual
- InterQual® Criteria Products: Adult and Pediatric (Level of Care: Acute Criteria), Inpatient Rehabilitation (Level of Care), Subacute/SNF (Level of Care), Home Care Q&A (Level of Care), (Level of Care) Outpatient Rehabilitation & Chiropractic, Procedures, Imaging, Specialty Rx Oncology, Specialty Rx Non-Oncology, Molecular Diagnostics, Durable Medical Equipment
- American College of Gynecology Guideline
PCHP uses the following clinical elements for determining Medical Necessity for behavioral health services:
- Assessment of local delivery system and network access
- Co-occurring conditions (SUD, medical, IDD)
- Coordination between BH and medical providers
- Current medications or medication changes
- Current symptoms (e.g. risk to self/others, psychosis, active substance use, relapse risk)
- Current treatment plan
- Diagnosis
- Discharge plan
- Family and social supports
- Functional impairment
- Presenting problem/reason for referral
- Psychosocial situation and home environment
- Response to treatment or barriers to treatment
Request for SUD services will be reviewed using ASAM criteria. Reviews will be largely structured around the 6 Dimensions. Providers will be expected to identify the level of care requested based on ASAM LOCs.
When requesting authorization for Court Ordered care, providers must submit a copy of the Court Order to PCHP. If a Court Order is not received, PCHP will process the request using appropriate Medical Necessity Criteria.