Community Care Medical Necessity Criteria For Pennsylvania Behavioral Health HealthChoices

Community Care uses the state of Pennsylvania “Appendix T” criteria for most levels of mental health care and for addictions services for adults.  These criteria can be viewed by clicking here for mental health services and clicking here for drug & alcohol services. If you cannot access these criteria via the website, please contact us for a paper copy. 

In addition, we use the American Society of Addiction Medicine Patient Placement Criteria for adolescent addiction services. To obtain these criteria, please contact Community Care and ask to speak to a manager or supervisor of the precertification team.

Some supplemental levels of care are not addressed in Appendix T.  Community Care has developed supplemental medical necessity criteria for these levels of care.  They include: Psychiatric Rehabilitation Services, Community Treatment Team, Acute Stabilization and Diversion, and Individual Residential Treatment/Community Residential Rehabilitation (CRR) Host Home.  Not all of these supplemental levels of care are available in each county.  Please find these medical necessity criteria below.

23-Hour Bed Rapid Assessment and Stabilization	20K	1 page	PDF
Acute Inpatient Mental Health	43K	2 pages	PDF
Acute Stabilization and Diversion - Adult	38K	2 pages	PDF
Acute Stabilization and Diversion - Child/Adolescent	16K	1 page	PDF
Adult Outpatient Treatment in an Alternative Setting	25K	3 pages	PDF
Community Treatment Team	40K	2 pages	PDF
Electroconvulsive Therapy	22K	3 pages	PDF
Family Focused Solution Based Services - Adult	23K	5 pages	PDF
Family Focused Solution Based Services - Child	23K	5 pages	PDF
IRT/CRR Host Home/TFC	54K	5 pages	PDF
Mobile Medication Team	17K	2 pages	PDF
Multisystemic Therapy	35K	4 pages	PDF
Psychiatric Rehabilitation	48K	2 pages	PDF
Psychological and Neuropsychological Testing	22K	3 pages	PDF
Residential Treatment Facility - Adults	18K	2 pages	PDF
Short-Term RTF - Acute Stabilization and Diversion Unit - Child/Adolescent	35K	2 pages	PDF

If the member's clinical condition necessitates a level of care that is covered in the member's benefit plan but that level of care is not available, the next highest covered benefit level of care will be authorized.