Partners has adopted Clinical Practice Guidelines from the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry.  Providers are responsible for following the Clinical Practice Guidelines adopted by Partners. Adherence to the guidelines is monitored through:

  • Focused audits by Partners’ Specialty Review Unit
  • Routine reviews of Service Authorization Requests (identifying areas of concern)
  • Peer review activities
  • Quality of Care Committee activities
  • Clinical Advisory Committee activities
  • Medical record audits by the Provider Network Department
  • Program Integrity monitoring, if indicated

Medical Necessity and/or Clinical Necessity Definition

Medical Necessity, and/or Clinical Necessity, references services that are necessary and appropriate for the prevention, diagnosis or treatment of a mental health, developmental disability or substance abuse condition, and are:

  • Consistent with Partners’ service definitions and other service guidelines
  • Individualized, specific and consistent with symptoms or confirmed diagnosis of the condition under treatment, and not in excess of the recipient’s needs
  • Able to be safely furnished, and no equally effective and more conservative or less costly treatment is available
  • Furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker or the provider
  • Not for experimental, investigational, unproven or solely cosmetic purposes
  • Furnished by or under the supervision of a practitioner licensed (as relevant) under NC state law in the specialty for which they are providing service and in accordance with federal and state laws and regulations, the Medicaid State Plan, The North Carolina Administrative Code, Medicaid clinical coverage policies, and other applicable federal and state directives
  • Sufficient in amount, duration and scope to reasonably achieve their purposes
  • Reasonably related to the diagnosis for which they are prescribed regarding type, intensity, duration of service and setting of treatment

Source: “LME UM Requirements and Procedures”, issued by the NC Division of Medical Assistance, November 14, 2008, section VII A and B.