Medical Necessity Criteria

SECTION	TITLE	DATE REVISED
1. 000	INTRODUCTION
1.100	Individuals Served by VBH-PA’s Public Sector Programs
1.200	Clinical Criteria Manual Development
2. 000	CLINICAL CRITERIA
2.000	Clinical Criteria Concepts
2.100	Assessment and Referral Risk-Rating Scale
2.200	Determining Clinical Necessity
2.300	Determining Appropriate Level of Care
2.301	Residential Treatment Facility – Adult
2.400	Evaluating Clinical Necessity for Continued Care
2.500	Discharge Criteria
2.503	Assertive Community Treatment (ACT) Criteria
3. 000	SERVICE MANAGEMENT
3.100	Overview
3.200	Outcomes
3.300	Individualized Service Plans
3.400	Coordination of Care
3.500	Discharge and Transition Plans
4.000	IN-PLAN ADULT MENTAL HEALTH SERVICES
4.100	Emergency/Crisis Services
4.101	Telephone Crisis Service
4.102	Walk-in Crisis Service
4.103	Mobile Crisis Service
4.200	Inpatient Programs
4.201	Acute Inpatient Mental Health
4.202	Subacute Inpatient Mental Health
4.300	Outpatient Treatment
4.300	Outpatient Psychotherapy Criteria
4.301	Outpatient Therapy
4.302	Psychological Testing
4.303	Family Therapy
4.304	Partial Hospitalization
4.306	Medication Management
4.307	Group Psychotherapy
4.308	Diagnostic Evaluation
4.309	Intensive Outpatient Programs (IOP) Adults
4.400	Case Management
4.401- 4.402	Intensive Case Management for Adults/Resource Coordination for Adults
4.500	Clozapine Support Services
4.501	Clozapine (Clozaril Management)
4.600	Electroconvulsive Therapy (ECT)
4.601	Electroconvulsive Therapy (ECT)
5.000	Pennsylvania’s Client Placement Criteria for Adults (PCPC)
	Level I (PCPC)
	Pennsylvania’s Client Placement Criteria for Adults (PCPC) Entire Document
	Outpatient (1A)
	Intensive Outpatient (1B)
	Level II (PCPC)
	Partial Hospitalization (2A) (Supplemental Service)
	Halfway House (2B)
	Level III (PCPC)
	Medically Monitored Inpatient Detoxification (3A)
	Medically Monitored Short-Term Residential (3B)
	Medically Monitored Long-Term Residential (3C)
	Level IV (PCPC)
	Medically Managed Inpatient Detoxification (4A)
	Medically Managed Inpatient Residential (4B)
	Pennsylvania’s Client Placement Criteria for Adults (PCPC) Special Populations and Considerations
	Methadone Maintenance Services
	Standard Level, Intense Level
	Comprehensive Psychiatric Evaluation
5.100	AMERICAN SOCIETY OF ADDICTION MEDICINE – ASAM FOR ADULTS
	ASAM Crosswalk with Pennsylvania’s System of Care
	ASAM Crosswalk
	Guidance for Application of ASAM in Pennsylvania’s Substance Use Disorder (SUD) System of Care
	Entire Document
	ASAM Level 1
	Outpatient (OP) Services
	ASAM Level 2.1
	Intensive Outpatient (IOP) Services
	ASAM Level 2.5
	Partial Hospitalization (PHP) Services
	ASAM Level 3.1
	Clinically-Managed Low Intensity Residential Services, i.e., Halfway House (HWH)
	ASAM Level 3.5
	Clinically-Managed High Intensity Residential Services (ST) – Adult
	Clinically-Managed Highest Intensity Residential Services (LT) – Adult
	ASAM Level 3.7
	Medically Monitored Inpatient Withdrawal Management – 3.7 WM
	Medically Monitored Intensive Inpatient Services
	ASAM Level 4
	Medically Managed Intensive Inpatient Withdrawal Management – 4 WM
	Medically Managed Intensive Inpatient Services – 4.0
6.000	IN PLAN CHILD/ADOLESCENT MENTAL HEALTH SERVICES
6.100	Emergency / Crisis Services
6.101	Telephone Crisis Service
6.102	Walk In Crisis Service
6.103	Mobile Crisis Service
6.200	Inpatient Programs
6.201	Acute Inpatient Mental Health
6.202	Subacute Inpatient Mental Health
6.300	Non-Hospital, Out-of-Home Placement
6.301	Residential Treatment (JCAHO and non-JCAHO)
6.302	Community Residential Rehabilitation Host Home
6.400	Outpatient Treatment
6.400	Outpatient Psychotherapy Criteria
6.401	Outpatient Therapy
6.402	Partial Hospitalization
6.403	Psychological Testing
6.404	Group Psychotherapy
6.405	Family Therapy
6.406	Medication Management
6.407	Diagnostic Evaluation
6.408	Intensive Outpatient Program (IOP) Child / Adolescent)
6.500	Case Management Services
6.502- 6.503	Resource Coordination & Intensive Case Management (Children / Adolescent)
6.600	Family Based Mental Health Services
6.601	Family Based Mental Health Services
7.000	IN PLAN ADOLESCENT DRUG AND ALCOHOL SERVICES
	For all levels of adolescent drug and alcohol services, please follow the American Society of Addiction Medicine (ASAM) patient placement criteria. http://www.asam.org/
8.000	BEHAVIORAL HEALTH REHABILITATION (EPSDT) SERVICES
8.000	Children and Adolescents BHRS Services Appendix T Part B (2)
9.000	SUPPLEMENTAL ADULT MENTAL HEALTH SERVICES
9.100	Residential Programs
9.103	Crisis Residential Services
9.104	Long Term Structured Residential Treatment Centers
9.200	Outpatient Treatment
9.201	Psychiatric Rehabilitation Program
10.000	SUPPLEMENTAL ADULT DRUG AND ALCOHOL SERVICES
10.101	Drug and Alcohol Intensive Case Management (Formerly, Targeted Case Management) For Adults
10.102	Drug and Alcohol Assessment / Level of Care determination
10.105	Partial Hospitalization (2A) (PCPC)
11.000	SUPPLEMENTAL CHILD/ADOLESCENT MENTAL HEALTH SERVICES
11.600	Crisis Residential Service
12.000	SUPPLEMENTAL CHILD/ADOLESCENT DRUG AND ALCOHOL SERVICES
12.101	Drug and Alcohol Intensive Case Management (Formerly, Targeted Case Management) For Children/Adolescents
13.000	OTHER ADULT MENTAL HEALTH SERVICES
13.100	Emergency/Crisis Services
13.101	Medical Mobile Crisis Team Service
13.102	23-Hour Assessment and Crisis Stabilization
13.103	23-Hour Crisis Observation, Evaluation, Holding, and Stabilization (Adult)
13.104	Non-Hospital Observation and Supervision
13.200	Outpatient Treatment
13.201	Acute Partial Hospitalization
14.000	OTHER CHILD AND ADOLESCENT MENTAL HEALTH SERVICES
14.100	Emergency/Crisis Services
14.101	23-Hour Crisis Observation, Evaluation, Holding, and Stabilization (Child / Adolescent)
14.102	Non-Hospital Observation and Supervision
14.103	Acute Partial Hospitalization
14.104	Medical Mobile Crisis Team Service
14.105	Multisystemic Therapy (MST)
14.106	Functional Family Therapy (FFT) Service
15.000	APPENDIX T HEALTHCHOICES BEHAVIORAL HEALTH SERVICES
15.101	Guidelines for Mental Health Necessity Criteria (Appendix T)
16.000	APPLIED BEHAVIORAL ANALYSIS USING BSC-ASD AND TSS FOR CHILDREN AND ADOLESCENTS WITH AUTISM SPECTRUM DISORDER
16.101	Applied Behavioral Analysis Using BSC-ASD and TSS for Children and Adolescents with Autism Spectrum Disorder