What is Clinically/Medically Appropriate Treatment?

The Mental Health and Chemical Dependency Benefits Program provides benefits only for clinically/medically appropriate treatment as determined by PBH and must meet all of the following conditions.

• It is rendered for the diagnosis or treatment of a mental disorder or chemical dependency;
• It is "appropriate", that is:
  1. It is consistent with the symptoms and the diagnosis;
  2. The type, level and length of service or supply and setting are within generally accepted standards for good medical practice within the organized medical community;
  3. For a hospital stay, acute care as an inpatient must be required for treatment or diagnosis and safe and adequate care cannot be received on an outpatient basis or in a less restrictive setting;
  4. To the extent that it is rendered by a professional, the professional is properly licensed or certified pursuant to applicable state and federal law and the care, treatment, or supply falls within the professional's scope of practice as provided by applicable federal and state law and the rules and regulations of any supervising professional organization;
  5. It is non-experimental treatment, which can be reasonably expected to improve the individual's condition or level of functioning;
  6. It is rendered at the least restrictive level of care providing effective treatment of the mental disorder or chemical dependency; and
  7. It is not mainly for the convenience of the Health Plan, the eligible participant or the eligible participant's health care provider.