Medical Necessity and Level of Care

Magellan Hawai’i believes that patients are best treated in the least restrictive environment consistent with the patient's symptoms, supports and safety requirements. The goal of treatment is the restoration of the patient to optimal functionality and independence.

This document is intended to be a starting point and common reference for clinical discussion and is based on a literature review of scientific evidence (see reference links below). As such, it focuses on the patient's clinical history, presenting symptoms and available resources in recommending a level of care. In addition, the Magellan Hawai’i's clinical staff reviewing the clinical information must consider the following issues when applying the criteria to a given individual: age, comorbidities, complications, progress of treatment, psychosocial situation, and home environment.

When a Care Manager determines that the requested service meets criteria, the care shall be authorized.

In those instances where a Case Manager determines that the clinical symptoms of the patient do not meet criteria and is therefore unable to authorize care, the case is forwarded to a Magellan Hawai’i Medical Director or Physician Advisor for review. Magellan Hawai’i Utilization Management Decisions, is followed in these instances.

Magellan Hawai’i also recognizes that resources for the full continuum of care do not exist in all local delivery systems. In such cases, Magellan Hawai’i may recommend a higher level of care than medically necessary in order to ensure safe, effective treatment. "Medical Necessity" is used here to describe care which is determined to be effective, appropriate and necessary to treat a given patient's disorder.

Review for level of care determination proceeds in a logical progression to confirm:

• The presence of a properly diagnosed mental health or substance abuse disorder amenable to the proposed course of treatment
• Symptoms are of a sufficient severity/complexity to meet the required criteria for admission to (or continued stay at) the requested level of care.
• The treatment is consistent with nationally accepted medical standards and there is no equally effective, less restrictive setting available to treat patient's current clinical condition.

Magellan Hawai’i attempts to avoid being too prescriptive and has generally not included discharge criteria, programmatic content, mandatory treatment interventions, etc., in these criteria. However, when a patient's level of stability/progress indicates that treatment can be safely and effectively treated at a lower level of care, discharge to a lower level of care shall be recommended.

An integral part of our Quality Improvement program is an annual review of these criteria, which examines developments in the professional literature as well as obtaining input from providers. We welcome your comments and suggestions at any time.

Reference Links

Click on the following reference link for additional information:

• Definitions for Levels of Care

Providers can gain access to medical necessity criteria used by logging onto HHIN+ below:

https://hhinplus.hmsa.com/HHINPlus/login

Revision History