Provider Manual

MEDICAL NECESSITY CRITERIA

For mental health services, VBH-PA, in cooperation with its Clinical Advisory Committee, has developed Medical Necessity Criteria (approved by the Commonwealth) that serves as a guide for the delivery of services at all levels of care. For substance abuse services, VBH-PA has utilized the Commonwealth’s Pennsylvania’s Client Placement Criteria (PCPC) for adults and the American Society of Addiction Medicine Patient Placement Criteria (ASAM PPC-2) for children and adolescents.

The PCPC will serve as a guide for both network providers and VBH-PA Service Management staff for requesting and providing service authorizations.

VBH-PA may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition.