Clinical Practice Guidelines and Recommendations

Our clinical and medical management teams use national guidelines and resources when making medical determinations. The resources include, but are not limited to:

• InterQual Guidelines
• CMS National Coverage Determination
• CMS Local Coverage Determination
• UptoDate
• Plan Developed Clinical Policies
  • Behavioral Health Residential Facility Criteria – Adults and Children
  • Adults Behavioral Health Therapeutic Homes
  • Therapeutic Foster Care for Children
  • Admission and Continued Stay Authorization Criteria for Behavioral Health Inpatient Facilities (BHIF) for persons under age 21/Residential Treatment Center

To obtain our national and state recognized medical necessity criteria applied to behavioral health and medical decisions, please contact us at 1-800-322-8670 (TTY: 711).

For more information about our care management programs, please call us at 1-800-322-8670 (TTY: 711).