Illinois Administrative Code
Title 50 - INSURANCE
Part 2035 - MEDICAL NECESSITY CRITERIA FOR SERIOUS MENTAL ILLNESSES FOR INDIVIDUALS UNDER THE AGE OF 26
Section 2035.30 - Medical Necessity Criteria for Utilization Review of Treatment Models for Serious Mental Illnesses for Individuals Under Age 26
Current through Register Vol. 48, No. 12, March 22, 2024
Any medical necessity criteria that an issuer, nonfederal governmental payor, or utilization review organization prescribes or uses for utilization review on any of the following interdisciplinary, team-based treatment models for serious mental illnesses in individuals under the age of 26 shall conform to the criteria in this Section. The services are delivered through the appropriate interdisciplinary team of mental health professionals to enable early treatment and recovery, improved functioning, improved and/or managed mental health symptoms, medication adherence, and the prevention of any further functional impairment. For individuals with Medicaid coverage, the medical necessity criteria will continue to be governed by the criteria established by the Illinois Department of Healthcare and Family Services.
a) Coordinated Specialty Care (CSC) for First Episode Psychosis Treatment
b) Community Support Team (CST) Treatment
* Continuous functional deficits in achieving treatment continuity or self-management of prescription medication;
* Persistent or severe psychiatric symptoms, serious behavioral difficulties, a co-occurring disorder, and/or a high relapse rate; or
* Danger of requiring acute level of care if more intensive services are not available.
c) Assertive Community Treatment (ACT)