Utilization Management

MHN monitors the utilization of behavioral healthcare services in order to facilitate the delivery of cost-effective behavioral healthcare.

When we talk about utilization you might think we're really talking about avoiding over utilization. In fact, the focus of our Utilization Management process is on care - the delivery of appropriate care in the appropriate setting. We believe that when the MHN care management team approves payment for only medically necessary care, both under and over-utilization are prevented. 

To reach decisions regarding medical necessity, care managers consider the following factors:

  • Patient characteristics such as severity of symptoms, severity of psychosocial stressors, acuity of symptoms, prior treatment efforts, the clinical diagnosis, and level of impairment in functioning; 
  • Clinical outcomes research and clinical practice/level of care guidelines; 
  • Local system and provider capabilities.

This process allows the Care Manager to answer the question, "Where and how can this patient be treated safely and most effectively in an environment that will promote optimal functioning?"

Underutilization poses its own set of problems. When patients do not receive the care they need initially, they may relapse, require treatment at a higher level of care, or be more likely to require a medical leave for a psychiatric disability.

At MHN we are aiming for optimal utilization in our care management and utilization management processes. 

For members covered under California commercial plans (HMO, EPO, PPO), MHN complies with SB855 state regulatory requirements and conducts utilization review of all covered mental health and substance use disorder services and benefits utilizing the criteria and guidelines set forth by the following nonprofit professional associations: 

LEVEL OF CARE CRITERIA

Clinical Specialty

Nonprofit Professional Association

Criteria or Guideline (Current Version)

Substance Use Disorder Any Age

American Society of Addiction Medicine (ASAM)

ASAM 3rd Edition 2013

Mental Health Disorders Members 18 and Older

American Association of Community Psychiatrists

Level of Care Utilization System (LOCUS) 20  2020
Mental Health Disorders Members 6 to 17 Years of Age

American Academy of Child and Adolescent Psychiatry

and                           

American Association of Community Psychiatrists and American Academy of Child and Adolescent Psychiatry

Child and Adolescent Level of Care Utilization System (CALOCUS) 20*  
Mental Health Disorders Patients 0 to 5 Years of Age

American Academy of Child and Adolescent Psychiatry

 Early Childhood Service Intensity Instrument (ESCII)

Enrollees, providers and members of the general public may request, at no cost, copies of clinical review criteria and any available training materials or resources.

  • Enrollees should call the Customer Service number located on your ID card, select the option for behavioral health and request to be transferred to the clinical team for assistance.
  • All others, please call 1-888-327-0010, select the option for member services (option 1), then select “0” to speak with a representative.     

Coverage for medically necessary treatment of mental health and substance use disorders, is provided under the same terms and conditions applied to other medical conditions. “Medically necessary treatment of a mental health or substance use disorder” means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is all of the following:

  • In accordance with the generally accepted standards of mental health and substance use disorder care;
  • Clinically appropriate in terms of type, frequency, extent, site, and duration; and
  • Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.

For Information and training offered by the nonprofit professional associations listed above, please visit the following links: (Please note by clicking thes links below you will be leaving the MHN website.)

American Academy of Child & Adolescent Psychiatry-Level of Care Utlization System/Child and Adolescent Level of Care Utlization System:

American Society of Addiction Medicine: