Behavioral Health Medical Necessity Criteria

Blue Cross and Blue Shield of Illinois (BCBSIL) licensed behavioral health clinicians will use the Milliman Care Guidelines®, Behavioral Health Guidelines, 14th Edition or BCBSIL Medical Policies as clinical screening criteria. 

Per Milliman Disclaimer, “The appropriate use of the Care Guidelines requires professional medical judgment and may require adaptation to consider local practice patterns. Professional medical judgment is required in all phases of the healthcare delivery and management process that should include consideration of the individual circumstances of any particular patient. The Care Guidelines are not intended as a substitute for this important professional judgment.” 

Milliman Care Guidelines is a clinical software package utilized to screen and evaluate for medical necessity and appropriateness of services which includes requests for acute inpatient admissions, Partial Hospitalization programs, Intensive outpatient programs, Residential Treatment Centers, and outpatient professional office visits. The application of the Milliman Care Guidelines by initial clinical reviewers and/or Physician Advisors, facilitates collection of the pertinent information required to authorize benefits for the requested behavioral health service, procedure, treatment and/or admission, and to determine length of stay (LOS) and/or frequency and duration of services requested, as well as, the appropriateness of the setting. A case that does not allow for approval based on Milliman Care Guidelines clinical screening criteria during a review performed by the initial clinical reviewers must always be referred to Physician Advisors for medical necessity determination. Physician Advisors will evaluate cases based on medical knowledge, experience and current standards of practice. 

Milliman Care Guidelines clinical screening criteria are:

  • Explicit, written, objective, clinically valid and compatible with established principles of health care;
  • Based on current clinical principles and processes;
  • Created by practicing clinicians involved in the development of appropriate criteria at all stages; thereby resulting in protocols which minimize data collection and reduce telephone time;
  • Designed to be flexible, allowing deviations from the norm, when justified, on an individual case basis;
  • Individualized with regard to LOS and review dates for each patient by age, diagnosis, procedure and co-morbid conditions;
  • Able to be modified as necessary to meet local standards of medical practice; and
  • Able to be overridden in the system by reviewers (initial clinical reviewers and/or Physician Advisors) to meet the needs of specific cases.

Milliman Care Guidelines are patient-centered and written by independent clinicians. They are evaluated at least annually or earlier if new data regarding indications or technologies becomes available. Final approval by the Medical Director, Behavioral Health is required. The criteria are then presented annually to the Behavioral Health Quality Improvement Committee for review and recommendation from community based network physicians and committee approval. 

Clinical Review Criteria are available to physicians and other professional providers upon request relative to a specific care review decision. Please contact BCBSIL Behavioral Health at (800) 851-7498 to initiate this request.