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    Medical Necessity Manual for Behavioral Health

    The Mihalik Group’s comprehensive Medical Necessity Manual for Behavioral Health guides utilization management decision-makers through the process of determining the most appropriate level of care for members presenting for mental health and substance use services. It is a symptom-driven set of criteria that focuses on the severity and degree of impairment caused by the member’s presenting situation.

    This distinguishes the Manual from a diagnostic-driven methodology which, in a field where diagnoses are frequently provisional and fluid, may lead to unnecessary or excessively intense medical services. This can mean that needless resources are being consumed by an already financially struggling industry. UM decision-makers like the Manual because it drives decisions for optimal care in a clear, concise and impartial manner. Providers like it because it presents the rationale for each decision in an easy-to-understand, objective manner.

    The Mihalik Group understands that medical necessity decisions involve consideration of two related, but distinct, dimensions:

    • The characteristics of the service setting
    • The medical necessity of the proposed services

    Knowing that services are medically necessary is not sufficient for good decision-making. It is essential to know which setting will deliver safe, effective treatment without providing excessive and unnecessary, or inadequate care. The Manual addresses both dimensions in a comprehensive and user-friendly format.

    In contrast to other sets of criteria that address only a few inpatient and outpatient settings, the Manual describes the characteristics of seventeen different service settings. This allows UM decision-makers to precisely match the clinical condition of an individual member with an appropriate service setting.

    The Manual contains treatment initiation and treatment continuation criteria for Adults and for Children and Adolescents and also for Geriatrics for each of the seventeen service settings, along with the process for applying the criteria. Each Level of Care Criteria set is intended to stand alone. This enables the decision-maker to find easily all relevant criteria in one place, reducing the amount of time needed to reach a determination.

    Because TMG continuously listens and responds to the needs of client organizations, criteria for psychological and neuropsychological testing, eating disorders, substance use requiring medical detoxification, and electroconvulsive therapy are included based on client requests. TMG recently released the Medical Necessity Manual for Behavioral Health, Version 8.1.0, which includes new criteria for Applied Behavior Analysis (ABA).

    Committed to maintaining the comprehensive and clinically relevant nature of the Manual , The Mihalik Group has established a National Advisory Panel. Members of the Panel are behavioral health specialists from a variety of backgrounds and experiences, including all levels of practitioners. The Panel conducts an annual review of the Manual and makes revisions to reflect changes in the managed behavioral health care field as well as the increasing diversification in the marketplace.

    If your organization is looking to maximize the value of your health care dollar while ensuring that appropriate services are being provided to your members, consider the Medical Necessity Manual for Behavioral Health . Your decision-makers will like it and so will your providers.

    View a   sample in PDF format.

    For more information about TMG’s health care consulting services and products, please e-mail us or call (773) 929-4276.

    1300 W. Belmont · Suite 500 · Chicago, IL 60657 · 773-929-4276

    © 2016 The Mihalik Group. All rights reserved.