Level of Care and Treatment Criteria

Effective April 24, 2006, MHN fully implemented the use of InterQual criteria for case review. InterQual can lead to improved consistency in decision making by evaluating patient-specific behaviors and symptoms to help make clinically appropriate decisions. This can empower our care managers to apply objective, evidence based criteria to support their level of care and continued stay decisions. Supporting appropriate care decisions can lead to better outcomes for our members. InterQual criteria are nationally recognized evidence based treatment guidelines produced by the McKesson Company.

All authorization decisions are reviewed using the InterQual criteria, however, in addition to meeting those criteria, MHN also reviews the plan of treatment for appropriateness and timeliness. Guidelines for elements considered in the treatment plan review, as well as the MHN clinical practice guidelines.

In accordance with the provisions of California Senate Bill 855, Effective 1/1/2021 for California Commercial HMO and PPO plans, MHN has implemented the use of Level of Care Utilization System and Child and Adolescent Level of Care Utilization System (LOCUS/CALOCUS), American Society of Addiction Medicine (ASAM), and Early Childhood Service Intensity Instrument criteria for all medical necessity determinations and level of care placement decisions. When the requested service is not in scope for LOCUS/CALOCUS, or another nonprofit professional association for the relevant clinical specialty, MHN will utilize InterQual criteria, if in scope, or internal criteria that have been developed according to generally accepted standards of mental health and substance use disorder care.

It is MHN's policy to share specific level of care guidelines in writing with contracted providers, members, customers and members of the general public who request them. Copies of criteria can be obtained by calling MHN:

For Providers:

Contact Professional Relations Department at MHN.ProviderServices@Healthnet.com

For Members:

Call the specific number listed on your card

  • ABA Services Medical Necessity (PDF)**
  • CMS National and Local Coverage Determinations (PDF)*