PacifiCare Behavioral Health (PBH) uses utilization managment criteria developed at a national level to make decisions about whether care and treatment are necessary, appropriate, and provided at the least restrictive level. These criteria are available to providers, members and the general public upon request. By adopting nationally recognized guidelines or criteria, PBH makes decisions based on reasonable medical evidence. The criteria are widely available to practitioners and can be assessed for the consistency with which they are used in making authorization or denial decisions. PBH informs its members about the guidelines in annual issues of its member newsletter Member Outlook. In addition, PBH notifies individual members and providers of the specific rule or criteria guideline that was used to make a denial of benefits decision in the denial letters it sends in addition to instructions about how to appeal the decision. The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered by the health plan. Except where otherwise mandated by State and Federal regulations, PBH uses two sets of UM Criteria based on sound clinical evidence. These have been shown to be reliable tools for objective authorization of benefits. 2004 Managed Care Appropriateness Protocol (MCAP) for Psychiatry and Outpatient Behavioral Health and 2001 American Society of Addiction Medicine (ASAM) Placement Guidelines for Substance Related Disorders- Version II - Revised. MCAP is used by PBH for treatment authorizations for persons with mental health disorders. The PBH UM Criteria are reviewed every year and updated if necessary based on feedback from actively practicing practitioners within the PBH network. The ASAM criteria are used for substance-related disorders. In some instances, State and Federal requirements mandate that PBH use a different set of guidelines to make authorization decisions. For example, the Texas Department of Insurance requires that PBH use clinical guidelines established by the State for the treatment of Substance Use Disorders for Texas members only. PBH also considers product-specific guidelines in making authorization decisions. For example, the Centers for Medicare & Medicaid Services (CMS) has established guidelines for Medicare Advantage members and expects that managed care plans use various methods of utilization management (e.g., prior authorization, concurrent review, discharge planning, retrospective review) to assure that care is appropriate (specific service, level of care, duration, and volume). Additionally, the plan conducts utilization management activities (e.g., pattern analysis and provider performance analysis) to assure the appropriateness of services and to assess patterns of care. PBH has obtained written permission to copy and distribute select pages from the MCAP and ASAM guidelines on a case-by-case basis. Due to copyright restrictions, PBH cannot make the entire set of guidelines available to providers on this website. The guidelines may be purchased in their entirety from the following links: To obtain the ASAM criteria, click on www.asam.org.  To obtain the MCAP criteria, click on http://oakgroup.com/html/ClinicalExcellence.htm Medically Necessary Behavioral Health Services PBH's policy regarding initial access to care is based on member demand and eligibility, rather than medical necessity criteria. All eligible members accessing care are directed to services at the appropriate level of care and the subsequent authorization of services is based on medical necessity criteria. Medical necessity determinations are made using the 2004 Managed Care Appropriateness Protocol or the 2001 ASAM criteria and the PBH endorsed Definition of Medical Necessity. The definition of medical necessity used by PBH was developed in March 1999 in a workshop sponsored by Stanford University's Center for Health Policy and the Integrated Healthcare Association. An intervention is medically necessary if, as recommended by the treating practitioner and determined by the health plan's medical director or designee, it is (all of the following): A healthcare intervention for the purpose of treating a behavioral health condition; The most appropriate supply or level of service, considering potential benefits and harms to the patient; Known to be effective in improving health outcomes. For new interventions, effectiveness is determined by scientific evidence. For existing interventions, effectiveness is determined first by scientific evidence, then by professional standards, then by expert opinion; and Cost-effective for this condition compared to alternative interventions, including no intervention. "Cost-effective" does not necessarily mean lowest price. When rendering these decisions, PBH ensures that a clinical reviewer is available to discuss the decision with the practitioner and that only appropriately licensed practitioners are rendering these decisions. Medically necessary does not always mean that a service is covered by the benefit plan. Certain benefit plans may contain a provision for mental health coverage only or chemical dependency coverage only. Coverage for certain treatments (e.g., detoxification) or treatment for certain disorders (e.g., compulsive gambling) may be excluded by a benefit plan. The plan sponsors with which PBH contracts (i.e., employer groups) determine benefit inclusions and exclusions. The plan sponsors also determine the benefit limits and co-payment/coinsurance levels, not otherwise subject to state laws or regulations. Back to To