Medical Necessity Criteria

Our medical necessity criteria (MNC), also known as clinical criteria, determine medical/clinical necessity and appropriate level of behavioral health care for individuals who receive services through MBHP programs.  The goal of these criteria is to promote recovery from the symptoms of mental illness and substance use disorders and to support the Member's stabilization at the highest level of functioning. 

Our medical necessity criteria are reviewed and updated at least annually to ensure they reflect the latest developments in serving individuals with behavioral health diagnoses.

Medical necessity criteria are a component of the MBHP Provider Manual, which is an extension of the Provider Agreement with MBHP.  

**Please note:
MBHP utilizes Change Healthcare’s InterQual Behavioral Health Medical Necessity Criteria for mental health levels of care; unless otherwise noted, MBHP custom criteria should be used.

MNC with a globe icon are linked to an outside web page, where providers can register and access those specific MNC through InterQual.  On that web page, click the "Registration" tab to get started.  For more information on InterQual MNC, please refer to Beacon/MBHP Broadcast 9.

MBHP also uses American Society of Addiction Medicine (ASAM) Criteria which focuses on substance use disorder treatment. Unless custom substance use disorder criteria exists, ASAM criteria is the criteria for substance use disorder treatment.

For information about the ASAM criteria, see An Introduction to the ASAM Criteria for Patients and Families. (Copyright 2015 by the American Society of Addiction Medicine. Reprinted with permission. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM.)

Inpatient Services

Inpatient services are provided in a 24-hour hospital setting and offer evaluation and treatment of acute mental health or substance use disorders.
globeInpatient Mental Health Services >
globeInpatient Mental Health Services for Persons with Developmental Disabilities or Autism Spectrum Disorder
download iconInpatient High-Intensity Services
globeInpatient Eating Disorder Services
Inpatient Substance Use Disorder Services (Level 4 Medically Managed Intensive Inpatient Withdrawal Management) - see ASAM Criteria
globe24-Hour Crisis Observation

Diversionary Services

Diversionary services are mental health and substance use disorder services that provide intensive support upon returning to the community after a Member has been in a hospital.  These services can be provided in a 24-hour facility or in a non-24-hour setting.

24-Hour Diversionary Services

Medically Monitored Inpatient Withdrawal Management – Level 3.7 (Adult/Adolescent Criteria) - see ASAM Criteria
download iconCommunity-Based Acute Treatment Services (CBAT)
download iconCommunity-Based Acute Treatment Services for Children and Adolescents with Autism Spectrum Disorder/Intellectual Disabilities (CBAT ASD/ID)
Individualized Treatment and Stabilization Services (ITS) - see ASAM Criteria Levels 3.7 and 3.5
Youth and Transition-Age Youth Detoxification and Stabilization Services - see ASAM Criteria levels 3.7 and 3.5
download iconIntensive Community-Based Acute Treatment Services (ICBAT)
Clinical Support Services (CSS) for Substance Use Disorders - see ASAM Criteria
download iconEnhanced Acute Treatment (E-ATS)
Residential Rehabilitation Services (RRS) - see ASAM Criteria
download iconCo-Occuring Enhanced RRS
download iconTransitional Care Unit (TCU)

Non-24-Hour Diversionary Services

download iconCommunity Support Program (CSP)
download iconCommunity Support Program for Individuals with Justice Involvement (CSP-JI)
download iconCommunity Support Program for Homeless Individuals (CSP-HI)
download iconCommunity Support Program Tenancy Preservation Program (CSP-TPP)
globeIntensive Outpatient Program (IOP) >
globePartial Hospitalization Program (PHP) >
download iconProgram of Assertive Community Treatment (PACT)
globePsychiatric Day Treatment >
Structured Outpatient Addiction Program (SOAP) - see ASAM Criteria

Outpatient Services

Outpatient mental health services are provided in places like clinics, community health centers, hospital outpatient departments, the Member's home, school, or other places in the community.  These services, which include individual therapy, group therapy, and family/couples therapy, help with a variety of mental health issues such as trauma, depression, anxiety, eating disorders, and adjustment disorders.  Outpatient substance use disorder services help with withdrawal from substances.  These services also support recovery from addiction.

download iconApplied Behavior Analysis (ABA)
Acupuncture Treatment for Withdrawal Management - see ASAM Criteria
Ambulatory Withdrawal Management - see ASAM Criteria
download iconAssessment for Safe and Appropriate Placement (ASAP)
download iconDialectical Behavioral Therapy (DBT)
download iconEarly Intensive Behavioral Intervention (EIBI)
globeOutpatient Professional Services >
Opioid Treatment Program (OTP) - see ASAM Criteria
download iconPsych Consultation on Inpatient Medical Unit-ED
globePsychological Testing >
download iconRecovery Coach (RC)
download iconRecovery Support Navigator (RSN)
globeRepetitive Transcranial Magnetic Stimulation (rTMS) >

Other Outpatient Services

globeElectroconvulsive Therapy (ECT) >

Community Behavioral Health Center (CBHC)

CBHC services are available 24 hours a day, 7 days a week, 365 days a year to anyone who is experiencing a mental health crisis. These services help reduce the immediate risk of danger to oneself or others. Community Behavioral Health Centers (CBHCs) and Mobile Crisis Intervention (MCI), available for both youth and adults, are provided within community-based locations.
download iconAdult Mobile Crisis Intervention (AMCI)
download iconYouth Mobile Crisis Intervention (YMCI)
download iconCommunity Crisis Stabilization (ACCS/YCCS)
download iconCertified Peer Specialis (CPS)

Behavioral Health Services for Children and Adolescents (BHCA)

Commercial Members Only
Behavioral Health Services for Children and Adolescents (BHCA), implemented by the Division of Insurance (DOI), is an effort to strengthen, expand, and integrate community-based services for the stabilization and support of families and their children with significant behavioral, emotional, and mental health needs.
download iconIntensive Care Coordination (ICC)
download iconFamily Support and Training - Family Partner (FS&T-FP)
download iconIn-Home Behavioral Services (IHBS)
download iconTherapeutic Mentoring (TM)

Children's Behavioral Health Initiative (CBHI) Services

The Children's Behavioral Health Initiative (CBHI) is an interagency effort of the Commonwealth's Executive Office of Health and Human Services (EOHHS).  Its mission is to strengthen, expand, and integrate Massachusetts state services into a comprehensive, community-based system of care to ensure that families and their children with significant behavioral, emotional, and mental health needs obtain the services necessary for success in home, school, and community.

Visit the CBHI Medical Necessity Criteria page >