Medical Necessity and Level of Care Determination Criteria 

 

Medical necessity is required by  all of the insurance companies I am credentialed with for coverage of services. You can still benefit from therapy even if you do not meet the criteria below, however I will not be able to bill your insurance. You may not meet criteria for medical necessity and/or Outpatient Level of Care at any point during your treatment. Eg. you reach your goals, significant improvement in functioning, not adhering to a treatment plan or responding to treatment or the severity of your symptoms require a higher level of care like inpatient hospitalization or intensive outpatient.

 

Outpatient Care This level of care is the least intensive level of treatment and represents the majority of care delivered. Psychiatric medication management visits are typically 15 minutes in length. Individual psychotherapy sessions occur for up to 60 minutes and group psychotherapy sessions for up to 90 minutes. This service is conducted in an office setting. 

 

A. Medical Necessity (All are required to consider for treatment) 

1. The patient must have been diagnosed with a psychiatric disorder by a licensed mental health professional. 

2. Symptoms of this illness must accord with those described in the Diagnostic and Statistical Manual of Mental Disorders, Edition V (DSM-V). 

3. The diagnosis must have been arrived at prior to admission in a face-to-face encounter between the professional and the patient. 

B. Admission Criteria (All must be met to recommend treatment) 

1. As a consequence of a DSM-V diagnosis, the individual is experiencing significant impairment in functioning in one or more of the following areas: 

  • Social  

  • Occupational  

  • Educational 

  • Family role 

2. The proposed treatment plan is focused on:  Adaptive responses to present impairments  Clearly defined and measurable goals, and  A defined time frame 

3. The patient has the requisite cognitive and emotional skills necessary to benefit from the proposed treatment plan. 

C. Continuing Care Criteria (All must be met to recommend continuing care) 

1. There is evidence that the patient is working to complete treatment goals and is attending sessions as scheduled. 

2. The patient continues to exhibit impairment requiring further treatment. 

3. The treatment plan clearly addresses the impairments necessitating ongoing care.