CurrentCareSourcePolicy N/A

Medical Necessity Determinations - AR PASSE (Administrative Policy Statement)

Defines CareSource's administrative policy for determining medical necessity for PASSE-covered services in Arkansas, including hierarchy of evidence and applicability to behavioral health parity; affects providers and PASSE program reviewers for Arkansas members.

Policy Summary

PayerCareSource

PolicyMedical Necessity Determinations - AR PASSE (Administrative Policy Statement)

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical/coverage changes

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionObtain required authorizations per the member's plan and document diagnoses with highest specificity to support medical necessity determinations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10/01/2024Policy Effective

Hierarchy of 6Evidence Sources

Case-by-caseNCSS Handling

MHPAEA appliedParity Noted

Coverage Criteria

Hierarchy for determining medical necessity

Policy Summary

PayerCareSource

PolicyMedical Necessity Determinations - AR PASSE (Administrative Policy Statement)

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical/coverage changes

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionObtain required authorizations per the member's plan and document diagnoses with highest specificity to support medical necessity determinations.

SourceLink

On This Page

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Hierarchy: (1) Federal or state regulation, including state waiver regulations when applicable; (2) Nationally accepted evidence-based clinical guidelines (e.g., MCG Health, InterQual, ASAM); (3) CareSource medical policy statements; (4) Professional judgment of the medical or behavioral health reviewer informed by resources including clinical practice guidelines published by consortiums of medical organizations, evidence from peer-reviewed studies (preferably ≥2 studies <5 years old; required <10 years), national panels and consortiums (e.g., NIH, CDC, AHRQ, NCCN, SAMHSA), commercial review organizations (e.g., UpToDate, Hayes, Inc.), consultation from like-specialty peers, and national specialty/subspecialty societies (e.g., American Psychiatric Association).

Exact numbered order is provided in policy text.

Provider Actions and Operational Rules

Prior Authorization

Authorization/payment not guaranteed

Authorization or payment is not guaranteed by this Administrative Policy Statement; coverage determinations remain subject to the member's benefit plan/Evidence of Coverage and PASSE authorization processes.

Step Therapy

Preference for conservative treatment

Medical necessity determinations prefer the least invasive, effective, and lower-cost alternative when available as part of defining an appropriate course of treatment.

Documentation Required

Document diagnosis specificity and acuity

Document diagnoses with the highest level of specificity, include specific descriptions of the patient’s condition, and identify whether conditions are emergent, acute, or chronic to support medical necessity determinations.

Denial Risk

Adhere to frequency/practice limits

Services may be limited or denied if provided more frequently than allowed under a national coverage policy, a local medical policy, or a clinically accepted standard of practice.

Background

Definitions of medical necessity vary among regulators and payers but commonly require that services be reasonable and necessary or appropriate for a patient’s condition and consistent with current standards of clinical practice. CareSource will determine medical necessity using the policy’s hierarchical evidence approach, and reviewers may limit or deny services that are provided more frequently than allowed by national/local medical policy or accepted clinical practice. Providers should document diagnoses with the highest level of specificity, include specific descriptions of the patient’s condition, and identify acute, emergent, or chronic status to support medical necessity determinations.

Definitions

Medically Necessary / Medical Necessity (policy definition)

Core 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; and where no other equally effective, more conservative, or less costly course of treatment is available or suitable. Determination may be made by the Medical Director for the PASSE Program or by the PASSE Program Quality Improvement Organization (QIO).

Scope of 'course of treatment'May include observation or, where appropriate, no treatment at all as part of determining medical necessity.

Decision authorityMedical necessity determinations may be made by the Medical Director for the PASSE Program or by the PASSE Program QIO.

Comparison standardService must be more effective, or there must be no equally effective, more conservative, or less costly alternative available or suitable for the beneficiary.

Nonmedical Community Supports and Services (NCSS)

Core definitionNonmedical supports and services that are necessary to protect the health and safety of members and enable safe living in the community.

Authority and availabilityNCSS are available under federal authorities (sections 1905, 1915(c), or 1915(i)) or under state authority (Act 775) through an AR Medicaid–enrolled provider as approved by a PASSE.

PurposeProvided to prevent or delay entry into an institutional setting or to assist or prepare a member to leave an institutional setting, supporting safe living in the member's home or community.

Need determinationNeed for NCSS is established by functional deficits identified on the Independent Assessment (ARIA) and actual services/supports are described in the PCSP.

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