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A physician reviews clinical practice guidelines

Clinical Practice Guidelines

The information below leads you to resources about clinical practice. This information is intended to be a resource for network physicians and other health care professionals. You may find the information helpful in diagnosing, managing or treating a clinical condition.

About the Clinical Practice Guidelines

Clinical Practice Guidelines

Humana Behavioral Health has adopted several clinical practice guidelines (CPG) from the American Psychiatric Association (APA) and the American Academy of Child and Adolescent Psychiatry (AACAP) to assist practitioners in making decisions regarding appropriate behavioral health care for specific clinical circumstances and to ensure consistency and improve patient care and safety.

These evidence-based guidelines are known to be effective in improving health outcomes. Humana Behavioral Health has chosen to adopt the practice guidelines for treatment of patients with bipolar disorder, major depressive disorder and substance use as our current focus guidelines in the adult population, as these diagnoses are among the most common for our members.

Humana Behavioral Health assesses compliance with clinical practice guidelines annually. The sample selection represents 50 percent of the high volume practitioners in each market where Humana Behavioral Health has business. High volume is defined as a practitioner who sees 10 or more enrollees three or more times in a 12-month period. Reviews are conducted in the practitioner’s office to allow for face-to-face contact and training. The performance goal is 85 percent. During record reviews, Humana Behavioral Health will focus on two elements for each guideline. A link for those elements is provided below.

Please note: The clinical practice guidelines are not a substitute for the sound clinical judgment of the behavioral health care practitioner and are intended only to assist the practitioner in making decisions about appropriate health care for specific clinical circumstances. Clinical practice guidelines may include treatment that requires prior authorization and/or may not be covered by the member’s health plan. All authorizations for care are based on medical necessity and are applied within the benefit plan structure.

Clinical Practice Resources

Bipolar Disorder

Major Depressive Disorder

Substance Use

Attention-Deficit/Hyperactivity Disorder

Elements for Annual Performance Measures

Printable Health Insurance Page From Humana