Insurance Companies' Medical Necessity Guidelines/Criteria

Posted By Kantorlaw || 20-Jun-2012

For patients seeking treatment of a severe mental illness such as an eating disorder, you will have to research the medically appropriate treatment for your needs and treatment provider. What you probably will not be told until you file a claim or seek authorization for insurance benefits, is that insurance companies and administrators have their own medical criteria or level of care guidelines which will be applied to your claim or request for authorization of benefits. Almost universally, insurance companies and employers do not disclose these guidelines and criteria in group health plans or insurance policies. Therefore, claimants are left in the dark as to what the insurance company is using to decide whether to pay your claim or approve your request for authorization.

To help you navigate through the process, here are links to the criteria or guidelines for some insurers and administrators that are available online:

United Behavioral Health (UBH) https://www.ubhonline.com/html/coverageDeterminationGuidelines.html

Anthem Blue Cross (California) http://www.anthem.com/ca/provider/f1/s0/t0/pw_e175468.pdf?refer=provider

Cigna http://www.cignabehavioral.com/web/basicsite/provider/pdf/levelOfCareGuidelines.pdf

Value Options http://www.valueoptions.com/providers/Handbook/clinical_criteria.htm

Magellan http://www.magellanprovider.com/MHS/MGL/providing_care/clinical_guidelines/MNC.asp

You will note that some insurers, such as Cigna, do not have specific guidelines for eating disorders but rather have guidelines only for levels of care.

The National Eating Disorder Association ("NEDA") toolkit provides a useful reference for explaining levels of care (http://www.nationaleatingdisorders.org/uploads/file/toolkits/NEDA-TKP-B04-TreatmentSettingsAndCare.pdf):

Inpatient

Patient is medically unstable as determined by:

- Unstable or depressed vital signs

- Laboratory findings presenting acute health risk

- Complications due to coexisting medical problems such as diabetes

Patient is psychiatrically unstable as determined by:

- Rapidly worsening symptoms

- Suicidal and unable to contract for safety

Residential (RTC)

Patient is medically stable and requires no intensive medical

intervention.

Patient is psychiatrically impaired and unable to respond

to partial hospital or outpatient treatment.

Partial Hospital (PHP)

Patient is medically stable but:

- Eating disorder impairs functioning, though without

immediate risk

- Needs daily assessment of physiologic and mental status

Patient is psychiatrically stable but:

- Unable to function in normal social, educational, or vocational situations

- Engages in daily binge eating, purging, fasting or very limited food intake, or other pathogenic weight control techniques

Intensive Outpatient/Outpatient (IOP or Outpatient)

Patient is medically stable and:

- No longer needs daily medical monitoring

Patient is psychiatrically stable and has:

- Symptoms under sufficient control to be able to function in normal social, educational, or vocational situations and

continue to make progress in recovery

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