Medical Necessity of Services

For members 21 years of age and older "Medically Necessary" or "Medical Necessity" is defined as services that a licensed provider, exercising prudent clinical judgment, would provide, in accordance with generally accepted standards of medical practice, to a recipient for the purpose of evaluating, diagnosing, preventing, or treating an acute or chronic illness, injury, or disease, or its symptoms, and that are:

  • Clinically appropriate in terms of type, frequency of use, extent, site, and duration, and consistent with the established diagnosis or treatment of the member’s illness, injury, disease, or symptoms.
  • Not primarily for the convenience of the member or the member’s family, caregiver, or health care provider.
  • No more costly than other items or services which would produce equivalent diagnostic, therapeutic, or treatment results as related to the member’s illness, injury, disease, or its symptoms.
  • Not experimental, investigative, cosmetic, or duplicative in nature [He-W 530.01(e)].

Per EPSDT/Healthchek for members under twenty-one (21) years of age, "Medically Necessary" means any service that is included within the categories of mandatory and optional services listed in Section 1905(a) of the Social Security Act, regardless of whether such service is covered under the Medicaid state plan, if that service is necessary to correct or ameliorate defects and physical and mental illnesses or conditions. The need for the item or service must be clearly documented in the member’s medical record.

AmeriHealth Caritas Ohio uses the following medical necessity criteria as guidelines for determinations related to medical necessity:

  • ODM Ohio Medicaid Provider Agreement for MCO
  • 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
  • NIA Radiology Guidelines
  • Avesis Dental Guidelines
  • Avesis Vision Guidelines

When applying these criteria, Plan staff also consider the individual member factors and the characteristics of the local health delivery system, including:

Member considerations

Age, comorbidities, complications, progress of treatment, psychosocial situation, social determinants of health, home environment, and compliance with parity in mental health and Substance Use Disorder treatment.

Local delivery system

  • Availability of sub-acute care facilities or home care.
  • AmeriHealth Caritas Ohio service area for post-discharge support.
  • AmeriHealth Caritas Ohio benefits for sub-acute care facilities or home care where needed.
  • Ability of local hospitals to provide all recommended services within the estimated length of stay.
  • Availability of the medically necessary behavioral health level of care.

Any request that is not addressed by or determined to not meet medical necessity guidelines is referred to the Medical Director or designee for a decision. Any decision to deny, alter or limit coverage for an admission, service, procedure or extension of stay, based on medical necessity, or to approve a service in an amount, duration or scope that is less than requested, is made by the Plan’s Medical Director or other designated practitioner under the clinical direction of the Vice President of Population Health Medical Services.

Medical Necessity decisions made by the Plan’s Medical Director or designee are based on the above definition of medical necessity, in conjunction with the member’s benefits, medical expertise, AmeriHealth Caritas Ohio medical necessity guidelines (as listed above), and/or published peer-review literature. At the discretion of the Plan’s Medical Director or designee, participating board-certified physicians from an appropriate specialty, other qualified healthcare professionals or the requesting practitioner/provider may provide input to the decision. The Plan’s Medical Director or designee makes the final decision.

Upon request by a member or practitioner/provider, the criteria used for medical necessity decision-making in general, or for a particular decision, is provided in writing by the Plan’s Medical Director or designee.

The Utilization Management staff involved in medical necessity decisions is assessed quarterly, and physicians involved in medical necessity decisions are assessed semi-annually for consistent application of review criteria. An action plan is created and implemented for any variances among staff outside of the specified range. Both clinical and non-clinical staff members are audited for adherence to policies and procedures.

Providers