MCG Health Behavioral Health Care Criteria (formerly known as Milliman Care Guidelines) is used for some plans, as noted on the Network-Specific Pages.

Medical Necessity Criteria can be found on that page.

Then, choose Access Clinical Information by clicking on the blue вЂњLearn MoreвЂќ button.

From the above link, choose the appropriate plan.

Unless custom criteria exists (e.g., LOCADTR in New York) or for Substance Use Lab Testing (which is found in in InterQual В® Behavioral Health Criteria), ASAM criteria is the criteria for substance use treatment services.

No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM.

The American Society of Addiction Medicine (ASAM) Criteria focuses on substance use treatment.

American Society of Addiction Medicine (ASAM) Criteria.

Beacon utilizes Change HealthcareвЂ™s InterQual В® Behavioral Health Medical Necessity Criteria for mental health levels of care and substance use lab testing, unless otherwise noted that Custom Criteria should be used.

Change HealthcareвЂ™s InterQual В® Behavioral Health Criteria.

For all Medicare members, first identify relevant NCD or LCD Criteria.The Medicare Coverage Database (MCD) to contains all National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).Centers for Medicare and Medicaid (CMS) Criteria.The following are BeaconвЂ™s Medical Necessity Criteria: Medical Necessity Criteria is available online via hyperlinks whenever possible and is available upon request. Historical criteria are provided for informational purposes only and are not subject to the same review process/timeframes. If 1-4 above are not met, BeaconвЂ™s National Medical Necessity Criteria would be appropriate.If the level of care is not substance use related, Change HealthcareвЂ™s Interqual В® Behavioral Health Criteria would be appropriate.* Exception: Substance Use Lab Testing Criteria is in InterQual В® Behavioral Health Criteria. If no custom criteria exists for the applicable level of care and the treatment is substance use related, the American Society of Addiction Medicine (ASAM) criteria would be appropriate.If no CMS criteria exists for Medicare members and for all non-Medicare members, identify relevant custom Medical Necessity Criteria.For all Medicare members, first identify relevant Centers for Medicare and Medicaid (CMS) National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) Criteria.To determine the proper Medical Necessity Criteria, use the following as a guide:

Medical Necessity Criteria varies according to state and/or contractual requirements and member benefit coverage. BeaconвЂ™s Corporate Medical Management Committee (CMMC) adopts, reviews, revises and approves Medical Necessity Criteria per client and regulatory requirements. BeaconвЂ™s Medical Necessity Criteria (MNC), also known as clinical criteria, are reviewed and updated at least annually to ensure that they reflect the latest developments in serving individuals with behavioral health diagnoses.

Mcg guidelines