24-765 Non-Profit Criteria for Select Medical Behavioral Health Conditions and Substance Use Disorders

Date: 07/17/24

Use the required criteria to determine medical necessity for certain services.

On January 12, 2024, the Office of Administrative Law approved the Department of Managed Health Care’s (DMHC’s) proposed regulation implementing SB 855. This regulation took effect April 1, 2024, and is codified in California Code of Regulations, title 28, sections 1300.74.72, 1300.74.72.01 and 1300.74.721. It mandates that health plans and their delegated participating physician groups (PPGs) use the latest criteria from nonprofit professional associations to determine medical necessity for select medical services related to behavioral health conditions and substance use disorders.

PPG Requirements

When medical services related to behavioral health conditions and substance use disorders are covered under the members’ benefit plan and prior authorization is required by the PPG for these specific services, PPGs delegated for medical necessity and utilization management are required to:

• Use the nonprofit professional association criteria for the relevant clinical specialty when reviewing medical mental health conditions and substance use disorders.
• Determine medical necessity on an individualized basis.

Services requiring nonprofit criteria 

For a detailed list of services that require adherence to nonprofit criteria, refer to
Cal. Code Regs. Title 28 CCR § 1300.74.72.01.

Nonprofit criteria requirements 

For a detailed list of utilization review requirements to determine medical necessity, refer to
Cal. Code Regs. Title 28 CCR § 1300.74.721.

If you have any questions, contact Provider Engagement.

This information applies to Participating Physician Groups (PPGs).