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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. 

In addition, we use the American Society of Addiction Medicine (ASAM) 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
ABA Services for Children/Youth with Autism Spectrum Disorder 196K 4 pages PDF
Acute Inpatient Mental Health 43K 2 pages PDF
Adult Outpatient Treatment in an Alternative Setting 25K 3 pages PDF
Community Treatment Team 40K 2 pages PDF
Diversion and Crisis Stabilization - Adult 22K 1 page PDF
Diversion and Crisis Stabilization - Child/Adolescent 22K 1 page 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
Multidimensional Treatment Foster Care 30K 3 pages PDF
Multisystemic Therapy 35K 4 pages PDF
Peer Support Services 41K 2 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.