Effective Jan. 1, 2023, Anthem Blue Cross and Blue Shield Medicaid (Anthem) will use MCG Care Guidelines criteria to determine medical necessity of both inpatient and outpatient precertification services, except in cases superseded by state Medicaid requirements. This action is based on the Commonwealth of Kentucky medical review criteria requirements, effective Jan. 1, 2023. The MCG Care Guidelines criteria will replace InterQual Guidelines review criteria. Please note: Existing precertification requirements have not changed. Health Care Management Services (HCMS) Behavioral Health department will continue to use the following criteria for reviews of behavioral health services if MCG Care Guidelines does not cover the service requested:
- Adults — Level of Care Utilization System (LOCUS)
- Substance use - American Society of Addiction Medicine (ASAM)
- Children and adolescents — Child and Adolescent Service Intensity Instrument (CASII)
- Young children — Early Childhood Service Intensity Instrument (ECSII)
Substance use disorder requests will continue to use American Society of Addiction Medicine (ASAM) criteria. All psychiatric and mental health services will continue to not require authorization due to the COVID-19 authorization waiver. Substance use disorder requests at the residential and inpatient levels of care will require prior authorization. If you have questions about this communication, please contact Provider Services at 855-661-2028.