Criteria for Medical Necessity

As an AmeriHealth Caritas Ohio member, you will receive all medically necessary Medicaid-covered services at no cost to you. Medically necessary means you need the services to prevent, diagnose, or treat a medical condition. The following criteria are used for Utilization Management determinations related to medical necessity:

• Ohio Department of Medicaid Provider Agreement for Managed Care Organization
• Ohio Administrative Code (OAC) & Rules
• Change Healthcare InterQual^® Level of Care Criterion
  • InterQual Acute Adult Criteria (Condition Specific- Responder, Partial Responder, Non-responder)
  • InterQual Acute Pediatric Criteria (Condition Specific-Responder, Partial Responder, Non-responder)
  • InterQual Outpatient Rehabilitation and Chiropractic Criteria
  • InterQual Home Care Criteria
  • InterQual Procedures Criteria
  • InterQual DME Criteria
  • InterQual Long-Term Acute Care (LTAC) Criteria
  • InterQual Rehabilitation (Acute Rehab) Criteria
  • InterQual Subacute/SNF Criteria
  • InterQual Criteria for Behavioral Health Adult and Geriatric Psychiatry Criteria
  • InterQual Criteria for Behavioral Health Child and Adolescent Psychiatry Criteria
  • InterQual Criteria for Behavioral Health Residential and Community Based Treatment
• American Society of Addiction Medicine (ASAM) Patient Placement Criteria (ASAM Admission Guidelines)
• American Society of Addiction Medicine (ASAM) Level of Care Adolescent Guidelines
• Corporate Clinical Policies
• National Imaging Associates Radiology Guidelines