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Medical Necessity Criteria

Learn more about the standards Humana Behavioral Health uses as a guide for utilization management decisions.

Effective through Feb. 14, 2016: The Mihalik Group’s Medical Necessity Manual for Behavioral Health

Humana Behavioral Health has adopted the Mihalik Group’s Medical Necessity Manual for Behavioral Health as the written clinical review criteria to apply when making all utilization management decisions for behavioral health care services that are not subject to applicable federal or state criteria.

The clinical criteria were developed by The Mihalik Group with guidance from a national panel of actively practicing physicians and other practitioners with current knowledge relevant to the criteria under review. The criteria are based on sound clinical principles and processes and are evaluated and updated by The Mihalik Group, as necessary, at least annually.

Additionally, Humana Behavioral Health's utilization management subcommittee reviews the approved criteria at least annually. Criteria used for an adverse determination are disclosed to the physician, practitioner, provider, patient and/or patient’s authorized representative in the written notification. Paper copies of the specific criteria used to make this determination are available upon request.

Effective Feb. 15, 2016, Humana Behavioral Health will no longer utilize the Mihalik Group’s Medical Necessity Manual for Behavioral Health as its clinical criteria. At that time, we will begin using the MCG Behavioral Health Care guidelines for behavioral health care services that are not subject to applicable federal or state criteria.

The clinical criteria were developed by MCG to describe best practices for the majority of behavioral health and substance use diagnoses — with guidance spanning the many levels and settings of the continuum of care.

Request Information:

To request a paper copy of the Mihalik Group's Medical Necessity Manual for Behavioral Health or the MCG Behavioral Health Care guidelines, please call 1-866-279-7214.

For utilization reviews or benefit determinations in Connecticut, Humana Behavioral Health follows the default criteria as outlined in the Connecticut General Statutes. (Section 72 of Connecticut Public Act No. 13-3). This includes utilization reviews or benefit determinations related to treating a substance use disorder, treating a mental disorder in a child or adolescent, or treating a mental disorder in an adult in commercial lines of business. Humana Behavioral Health follows the applicable local or national determination criteria for Medicare lines of business.

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