Medical Necessity Criteria

Learn more about the standards Humana Behavioral Health uses as a guide for utilization management decisions.

Effective Feb. 15, 2016, Humana Behavioral Health no longer uses the Mihalik Group’s Medical Necessity Manual for Behavioral Health as its clinical criteria. We now use the MCG Behavioral Health Care guidelines for behavioral health care services that are not subject to applicable federal or state criteria.

MCG Behavioral Health Care

Humana Behavioral Health has adopted MCG Behavioral Health Care as the written clinical review criteria to apply when making all utilization management decisions for behavioral health care services unless state or federal law mandates the use of other criteria.

The clinical criteria were developed by MCG to describe best practices for the majority of behavioral health and substance use diagnoses — with guidance spanning the many levels and settings of the continuum of care.

Humana Behavioral Health's utilization management subcommittee reviews the approved criteria at least annually. Criteria used for an adverse determination are disclosed to the physician, practitioner, provider, patient and/or patient’s authorized representative in the written notification. Paper copies of the specific criteria used to make this determination are available upon request.

Request Information:

To request a paper copy of MCG Behavioral Health Care, please call 1-877-264-2548.

For utilization reviews or benefit determinations in Connecticut, Humana Behavioral Health follows the default criteria as outlined in the Connecticut General Statutes (Section 72 of Connecticut Public Act No. 13-3). This includes utilization reviews or benefit determinations related to treating a substance use disorder, treating a mental disorder in a child or adolescent, or treating a mental disorder in an adult in commercial lines of business. Humana Behavioral Health follows the applicable local or national determination criteria for Medicare lines of business.