Behavioral Health Medical Necessity Criteria

PW_B125770
The Office of Medical Policy and Technological Assessment (OMPTA) has developed policies that serve as one of the sets of guidelines for coverage decisions. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Policy does not constitute plan authorization, nor is it an explanation of benefits.  
Policies can be highly technical and complex and are provided here for informational purposes. The policies do not constitute medical or behavioral health advice or care. Treating health care providers are solely responsible for diagnosis, treatment and advice. Health plan members should discuss the information in the policies with their treating health care providers. 
Technology is constantly evolving and these policies are subject to change without notice. Additional policies may be developed from time to time and some may be withdrawn from use. The policies generally apply to all fully-insured benefit plans, although some local variations may exist. Additionally, some benefit plans administered by the health plans, such as some self-funded employer plans or governmental plans, may not utilize these policies. Members should contact their local customer service representative for specific coverage information. 
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