Clinical Practice Guidelines Overview
Partners Health Management adopts Clinical Practice Guidelines from the American Psychiatric Association (APA) and the American Academy of Child and Adolescent Psychiatry (AACAP). Providers are responsible for adhering to these guidelines.
Adherence is monitored through:
- Routine reviews of service authorization requests
- Peer review activities
- Clinical Advisory Committee activities
- Medical record audits by the Quality Management Department
- Program Integrity monitoring, as indicated
Medical Necessity
Medical necessity is the determination that a covered service is clinically appropriate for the member based on applicable criteria and organizational policy.
Medically necessary services:
- Align with clinical coverage policies, state-funded service definitions, Partners’ in-lieu-of service definitions and other service guidelines
- Are individualized, specific to the member’s symptoms or confirmed diagnosis and not excessive
- Can be safely furnished, with no equally effective, more conservative or less costly alternative available
- Are not primarily for the convenience of the member, caregiver or provider
- Are not experimental, investigational, unproven or solely cosmetic
- Are provided by, or under the supervision of, a practitioner licensed in North Carolina in the relevant specialty and in accordance with federal and state laws and regulations, Medicaid plan guidelines, the North Carolina Administrative Code, Medicaid clinical coverage policies and other applicable directives
- Are sufficient in amount, duration and scope to reasonably achieve their purpose
- Are reasonably related to the diagnosis in type, intensity, duration and treatment setting
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