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Behavioral Health Medical Necessity Criteria

The following information describes the Medical Necessity care guidelines utilized by Blue Cross and Blue Shield of Illinois (BCBSIL) for its group, retail and government products. Similar behavioral health programs are implemented across product lines but requirements may vary dependent upon the product. 

The BCBSIL Behavioral Health (BH) Team utilizes nationally recognized, evidence based and/or state or federally mandated clinical review criteria for all of its behavioral health clinical decisions.

For its group and retail membership, BCBSIL licensed behavioral health clinicians utilize the MCG care guidelines for mental health conditions. BCBSIL BH licensed clinicians utilize the American Society of Addiction Medicine’s The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions for addiction disorders. In addition to medical necessity criteria/guidelines, BH licensed clinicians utilize BCBSIL Medical Policies, nationally recognized clinical practice guidelines (located in the Clinical Resources section of the BCBSIL website) and independent professional judgment to determine whether a requested level of care is medically necessary. The availability of benefits will also depend on specific provisions under the member’s benefit plan.

For membership in the following government programs – Blue Medicare AdvantageSM, Blue Cross Community Family Health Plan (FHP)SM, Blue Cross Community Integrated Care Program (ICP)SM, and Blue Cross Community MMAI (Medicare-Medicaid)SM – BCBSIL BH licensed clinicians utilize the following hierarchy of clinical criteria to assist in determinations for the most appropriate level of care for our members: National Coverage Determinations (NCD), Local and Regional Coverage Determinations (LCD), MCG care guidelines (mental health disorders), the American Society of Addiction Medicine’s The ASAM Criteria (addiction disorders), BCBSIL Medical Policies, and nationally recognized clinical practice guidelines.

The appropriate use of treatment guidelines requires professional medical judgment and may require adaptation to consider local practice patterns. Professional medical judgment is required in all phases of the health care delivery and management process that should include consideration of the individual circumstances of any particular member. The guidelines are not intended as a substitute for this important professional judgment.

BCBSIL evaluates and approves all of the above listed medical necessity guidelines at least annually or earlier if new data regarding indications or technologies becomes available. Final approval by the Behavioral Health Chief Medical Officer 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 for 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.