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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 substance use disorder services. If you cannot access these criteria via the website, please contact us for a paper copy. 

Community Care also uses the State of Pennsylvania "Appendix S" Medical Necessity Guidelines in reviewing BHRS relating to Applied Behavior Analysis using BSC and TSS Services for children and youth with diagnoses of Autism Spectrum Disorders. These Guidelines can be viewed by clicking here. If you cannot access these guidelines via the website, please contact us for a paper copy.

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 147K 2 pages PDF
Acute Inpatient Mental Health 149K 3 pages PDF
Adult Acute Stabilization and Diversion 117K 2 pages PDF
Community Treatment Team 123K 3 pages PDF
Child and Adolescent Acute Stabilization and Diversion 149K 2 pages PDF
Adult Diversion and Crisis Stabilization Residential Services 127K 2 pages PDF
Child and Adolescent Diversion and Crisis Stabilization Residential Services 128K 2 pages PDF
Electroconvulsive Therapy 133K 4 pages PDF
Family Focused Supplemental Services: Adult 135K 6 pages PDF
Family Focused Supplemental Services: Child and Adolescent 158K 6 pages PDF
Behavioral Health Rehabilitation Services (BHRS) Functional Family Therapy (FFT) 189K 6 pages PDF
Individual Residential Treatment (IRT)/Community Residential Treatment (CRT)/Community Residential Rehabilitation (CRR) Host Home/Therapeutic Foster Care (TFC) 179K 6 pages PDF
Mental Health/Adult Outpatient Treatment in an Alternative Setting 131K 2 pages PDF
Mobile Medication Team 126K 2 pages PDF
Behavioral Health Rehabilitation Service (BHRS) - Multisystemic Therapy (MST) 178K 5 pages PDF
Multidimensional Treatment Foster Care 155K 3 pages PDF
Peer Support Services 122K 3 pages PDF
Psychiatric Rehabilitation 129K 2 pages PDF
Psychological and Neuropsychological Testing 140K 4 pages PDF
Residential Treatment Facility - Adults 145K 2 pages PDF
Child and Adolescent Short-Term RTF - Acute Stabilization and Diversion Unit 149K 3 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.