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:
- It is consistent with the symptoms and the diagnosis;
- 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;
- 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;
- 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;
- It is non-experimental treatment, which can be reasonably expected to
improve the individual's condition or level of functioning;
- It is rendered at the least restrictive level of care providing effective
treatment of the mental disorder or chemical dependency; and
- It is not mainly for the convenience of the Health Plan, the eligible
participant or the eligible participant's health care
provider.
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