CurrentCareSourcePolicy N/A

Medical Necessity Determinations — Arkansas PASSE

Defines how CareSource determines medical necessity for services under the Arkansas PASSE program, including hierarchy of references and applicability to behavioral health parity; affects providers and reviewers of PASSE-covered services in Arkansas.

Policy Summary

PayerCareSource

PolicyMedical Necessity Determinations — Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionApply the defined five-step hierarchy when determining medical necessity for PASSE-covered services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5hierarchy sources

MHPAEAparity applied

10/01/24–12/31/25effective dates

4revision entries

Coverage and Medical Necessity Criteria

Medical Necessity Determination Criteria

Policy Summary

PayerCareSource

PolicyMedical Necessity Determinations — Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionApply the defined five-step hierarchy when determining medical necessity for PASSE-covered services.

SourceLink

On This Page

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Provider Responsibilities and Determination Hierarchy

Note

Medical necessity determination hierarchy — benefit contract, regulations, CareSource policies, national guidelines, reviewer judgment

Medical necessity determinations are made using a clear hierarchy. CareSource reviewers will apply the plan benefit contract (Evidence of Coverage) first, then applicable federal or state regulations (including waiver rules), followed by CareSource medical policy statements, nationally accepted evidence-based clinical guidelines (for example, MCG Health, InterQual, ASAM), and finally the professional judgment of the medical or behavioral health reviewer informed by accepted clinical practice guidelines and peer-reviewed evidence.

A. Benefit contract language (Evidence of Coverage) — controlling when conflicts exist.
B. Federal or state regulation, including state waiver regulations when applicable.
C. CareSource medical policy statements.
D. Nationally accepted evidence-based clinical guidelines (e.g., MCG Health, InterQual, ASAM).
E. Professional judgment of the medical or behavioral health reviewer, supported by clinical practice guidelines and peer-reviewed evidence (preferably ≥2 studies <5 years; required <10 years).

Documentation Required

Medical record documentation — specificity of diagnoses, description of condition, emergent/acute identification

Providers must ensure medical records and claim documentation support the requested service with specificity. Include precise diagnosis coding (highest level of specificity), clear descriptions of the member's condition, and whether the presentation is emergent, acute, or chronic to substantiate medical necessity.

Use ICD guidance to select the code that accurately describes the clinical condition or reason for visit.
Document diagnosis specificity, condition description, and emergent/acute status in the medical record.

Denial Risk

Triggers for non-coverage or denial — conditions that do not guarantee coverage (physician performed/prescribed alone insufficient, sole available treatment alone insufficient)

The following are examples of triggers that do NOT by themselves guarantee coverage or payment and may lead to denial if unsupported by the hierarchy and documentation: a physician's order or performance of a procedure; the treatment being the only available option; or a physician's sole determination that a service is medically necessary. Providers should not rely solely on these factors — supporting documentation and alignment with the determination hierarchy are required.

A physician has performed or prescribed a procedure or treatment — not sufficient alone.
The procedure or treatment is the only available treatment option — not sufficient alone.
A physician's determination that a service is medically necessary or appropriate — not sufficient alone without supporting documentation and alignment to policy/regulation/guidelines.

Prior Authorization

(Provider note) Evidence and contract alignment required for reviewer consideration

Providers: highlighted action — ensure all requests reference the plan contract and applicable regulations, include guideline-based rationale, and attach supporting peer-reviewed evidence or clinical guideline citations when relevant.

Reference the Evidence of Coverage and any applicable state/federal rules in authorization requests.
Attach guideline citations or peer-reviewed studies when clinical necessity is not clearly established by contract or policy.

Background

Definitions of medical necessity vary among payors and regulators but generally require that services be reasonable and necessary and appropriate given the patient’s condition and current clinical standards. CareSource applies a defined hierarchy when making medical necessity determinations: (1) benefit contract language; (2) federal or state regulation (including waiver rules); (3) CareSource medical policy statements; (4) nationally accepted evidence-based clinical guidelines (e.g., MCG, Interqual, ASAM); and (5) the professional judgment of the medical or behavioral health reviewer using specified resources. Providers should document diagnoses with the highest level of specificity and clinical details in the medical record to support medical necessity decisions.

Key Definitions

Medically Necessary / Medical Necessity

DefinitionA service reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent worsening of conditions that endanger life, cause suffering or pain, result in illness or injury, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction; no other equally effective, more conservative, or less costly course of treatment is available or suitable. Determination may be made by the PASSE Medical Director or the PASSE QIO.

DeterminerMedical Director for the PASSE Program or the PASSE Program Quality Improvement Organization (QIO) may make the determination of medical necessity.

Treatment alternativesA 'course of treatment' may include observation or, where appropriate, no treatment at all when clinically indicated.

Nonmedical Community Supports and Services (NCSS)

DefinitionNonmedical Community Supports and Services (NCSS) are nonmedical supports necessary to protect health and safety and enable safe living in the community; available under federal authorities (sections 1905, 1915(c), 1915(i)) or state authority (Act 775) as approved by a PASSE and provided to prevent or delay institutionalization or assist/prepare a member to leave an institution.

Eligibility determinationNeed for NCSS is established by functional deficits identified on the Independent Assessment (ARIA).

DocumentationActual services and supports are described in the person-centered service plan (PCSP).

Clinical componentHCBS services with a clinical component must use the medical necessity standard.

MHPAEA (Mental Health Parity and Addiction Equity Act)

LawMental Health Parity and Addiction Equity Act (MHPAEA) is a 2008 federal law that prevents health plans and issuers from imposing less favorable benefit limitations on mental health and substance use disorder benefits than on medical/surgical coverage.

Application in policyUnder MHPAEA, coverage for diagnosis and treatment of behavioral health disorders will not be subject to limitations less favorable than those for medical conditions as covered under this policy.

Reviewer obligationReviewers must determine medical necessity using the specified hierarchy while ensuring parity requirements are met.