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Coverage criteria policies

Eating disorder coverage criteria

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

All residential services require prior authorization, including those for the treatment of an eating disorder.

Notification is required for all inpatient admissions, including those for the treatment of an eating disorder.

Concurrent review is required for all inpatient treatment at a non-contracted facility, including those for the treatment of an eating disorder.

Please contact the Behavioral Health Department at 952-883-7501 for authorization or fax clinical to 952-853-8830.

Coverage

HealthPartners follows the Milliman Care Guidelines (MCG) Behavioral Health Care 22nd edition for all levels of care including outpatient, residential and inpatient treatment. Please contact the Behavioral Health Department at 952-883-7501 for a copy.

Eating Disorder Treatment is generally covered subject to your plan documents.

An eating disorder assessment and relevant clinical information must be reviewed by a Behavioral Health Coordinator and a board certified Psychiatrist and prior authorization obtained prior to admission for residential care.

Indications that are not covered

  1. Member does not meet DSM-5 diagnostic criteria for an eating disorder
  2. Clinical information submitted and reviewed does not meet the Milliman Coverage Criteria for the requested level of care.
  3. Services do not meet the definition of medical necessity in the member’s plan.
  4. Member’s plan does not cover services requested.

Definitions

Outpatient treatment: Generally individual, group, and/or family weekly therapy sessions.

Residential: Provides 24 hour, structured and supervised living for members who have not responded to lower levels of care

Inpatient Care: This is a medically necessary continuous confinement in a hospital lasting 24 hours or more that includes charges for room and board and provides 24 hour nursing for the acute care of a mental health diagnoses as described in the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM 5) (most recent edition) that leads to significant disruption of functioning or becoming a threat to self or others.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. MCG Behavioral Health Care 22nd Edition, Copyright © 2018 MCG Health, LLC., Last Update: 1/30/2018 6:28:02 PM Build Number: 22.0.99237.004578 Version 22.0

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Policy activity

  • 08/03/2016 - Date of origin
  • 05/08/2018 - Effective date
Review date
  • 05/2018
Revision date
  • 05/08/2018

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