Medical Necessity Criteria

Beacon of California’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. Beacon of California’s Corporate Medical Management Committee (CMMC) adopts, reviews, revises and approves Medical Necessity Criteria per client and regulatory requirements.

Medical Necessity Criteria varies according to state and/or contractual requirements and member benefit coverage. To determine the proper Medical Necessity Criteria, use the following as a guide:

  1. For all Medicare members, first identify relevant Centers for Medicare and Medicaid (CMS) National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) Criteria.
  2. If no CMS criteria exists for Medicare members and for all non-Medicare members, identify relevant custom Medical Necessity Criteria.
  3. 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.
    * Exception: Substance Use Lab Testing Criteria is in InterQual® Behavioral Health Criteria.
  4. If the level of care is not substance use related, Change Healthcare’s Interqual® Behavioral Health Criteria would be appropriate.
  5. If 1-4 above are not met, Beacon of California’s Medical Necessity Criteria would be appropriate.

Medical Necessity Criteria is available online via hyperlinks whenever possible and is available upon request.

The following are Beacon of California’s Medical Necessity Criteria:

  1. Centers for Medicare and Medicaid (CMS) Criteria
    • The Medicare Coverage Database (MCD) to contains all National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).
    • For all Medicare members, first identify relevant NCD or LCD Criteria.
  2. Change Healthcare’s InterQual ® Behavioral Health Criteria
    • Effective September 21, 2019, Beacon of California will begin using Change Healthcare’s InterQual® Behavioral Health Medical Necessity Criteria, unless there is an otherwise noted Custom Criteria set.
  3. American Society of Addiction Medicine (ASAM) Criteria
    • The American Society of Addiction Medicine (ASAM) Criteria focuses on substance use treatment.
      Copyright 2015 by the American Society of Addiction Medicine. Reprinted with permission. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM.
    • For information about The ASAM Criteria, see the Introduction to The ASAM Criteria for Patients and Families
    • Unless custom criteria exists or for Substance Use Lab Testing (which is found in in InterQual® Behavioral Health Criteria), ASAM criteria is the criteria for substance use treatment services.
  4. Custom Criteria

If you need assistance identifying the correct criteria, contact Beacon of California.