Medical Necessity Criteria (MNC)

The Comprehensive Needs Assessment must document the need for crisis stabilization services. To qualify for this service, individuals must demonstrate a clinical necessity for the service arising from a condition due to an acute crisis of a psychiatric nature that puts the individual at risk of psychiatric hospitalization.

Service authorization is based on medical necessity and there will time when the UM team needs clinical to be able to determine the appropriateness of the service. Daily service provision is limited to the times when the individual meets the clinical necessity and service definition requirements.

Individuals must meet at least two of the following criteria at the time of admission to the service:

  1. Experiencing difficulty in establishing and maintaining normal interpersonal relationships to such a degree that they are at risk of psychiatric hospitalization or homelessness or isolation from social supports.
  2. Experiencing difficulty in activities of daily living (ADLs) such as maintaining personal hygiene, preparing food and maintaining adequate nutrition, or managing finances to such a degree that health or safety is jeopardized.
  3. Exhibiting such inappropriate behavior that immediate interventions by mental health, social services, or the judicial system are or have been necessary.
  4. Exhibiting difficulty in cognitive ability (such that the individual is unable to recognize personal danger or recognize significantly inappropriate social behavior).

Room and Board Limitation: Room and board, custodial care, and general supervision are not components of this service.

Please see Chapter IV pages 44 - 47 of the DMAS MHS Manual for a complete listing of service limitations.

What can providers expect from the UM staff in the authorization review process?

  • UM staff will collaborate with participating providers to support registrations and authorization requests.
  • Providers should ensure the registrations and service request authorizations are completed in their entirety.
  • UM staff may reach out to the clinical contact listed on the registration or SRA to request any additional information needed to determine if the member meets the medical necessity criteria. To expedite this process, please ensure that:
    • Ensure the clinical contact information is correct
    • Make sure that the clinical contact is a person that can discuss and provide any clinical information
    • Please be responsive with requests for additional information to ensure the review is completed timely. Not submitting the requested information can delay the authorization request or result in a denial
  • Providers can expect the UM reviewer to call for additional information when the following information is not documented in the request:
    • Current acute psychiatric crisis
    • Care coordination with collateral providers
    • Linkage to recommended services
    • Discharge planning with the member
    • If needed, the Comprehensive Needs Assessment, to determine medical necessity for the service

What can providers expect from the care coordination staff?

  • As a part of Optima Health’s provider network, providers are expected to engage in active care coordination with the health plan.
  • Optima Health care coordinators partner with providers to support member’s recovery and resiliency goals by ensuring the appropriate resources and services are in place.
  • Care coordination staff will engage providers in active discharge and transition planning by sharing individualized recommendations and referrals.
  • Providers may be asked to participate in treatment team meetings initiated and facilitated by care coordination, as part of the active care coordination.
  • Care coordination will also engage members in discussions around transition planning, as they make progress towards their goals and will follow the member 30 days after transitioning from Crisis Stabilization to ensure they are following the recommendations and have wrap around services in place.

How can the service request reflect individualized treatment for Crisis Stabilization?

Optima reviews the request form, clinical documentation, and the service plan for alignment of units, duration, and goals. Request and clinical should include:

  • Current acute psychiatric crisis: who, what, when, where, how often?
  • Document services that member is being linked to post-acute crisis to maintain stability in the community and reduce the risk of future acute crisis.
  • Identify barriers and specific strategies to overcome those barriers.
  • Include goals and interventions that target the member’s specified acute crisis.
  • Avoid vague goals that are so broad that progress cannot be specifically measured.

Learn more about Medical Necessity Criteria