Clinical Utilization Management

Medical Necessity Criteria
BHI has established Medical Necessity Criteria that serve as the basis for consistent and clinically appropriate service authorization decisions. Click the link above for more information.

Access to Care Standards
All BHI providers are expected to provide services to Medicaid members within certain guidelines. Please reference BHI policy UM-801 Access and Availability for complete information about access to care standards and monitoring. Here you will find more information surrounding the criteria BHI adheres to for Access to Care Standards.

Advance Directives
Advance Directives are written instructions recognized under State law relating to the making of medical treatment decisions and the provision of health care when or if an individual is incapacitated. It is the policy of BHI to follow applicable State law and Federal Regulations regarding advance directives and to provide adult members with written information on advance directives and BHI’s advance directive policy. Please reference the BHI policy OMFA-601 Advance Directives for more information.

Authorization Forms
Your contractual arrangement with BHI is the Provider Services Agreement (PSA). The PSA indicates that covered services must be medically necessary, appropriate, and delivered in an appropriate, timely, least restrictive and cost effective manner. Click here for Authorization Forms.

Clinical Practice Guidelines
BHI develops, implements, monitors, and evaluates clinical practice guidelines, medication algorithms, and new technology based on current standards of practice. BHI expects that all providers adhere to all BHI practice guidelines. BHI reviews data regarding compliance with current guidelines, identifies education opportunities, and makes recommendations for performance improvement.

Clinical Documentation Forms
Consistency is a major initiative in the quest to improve quality reporting and accurate claims submission for behavioral health (BH) services. Adherence to industry standards and approved coding principles ensure quality along with consistency in the reporting of these services. Click here to find the best practice guidance for Clinical Documentation.