Medical Necessity in Private Health Plans: Implications for Behavioral Health Care

About the Course:

This report addresses how the term “medical necessity” is defined in private health insurance coverage decisions. It summarizes a review of the literature, an extensive review of legal cases that challenge insurer decisions, materials prepared by the insurance industry, consultation with experts in the field, a review of investigations conducted by state departments of insurance and attorneys general, and interviews with health care executives regarding the decision making process itself. The report does not explore factors that can affect access to care that might be considered clinically necessary by treating professionals or the effects of medical necessity decisions on therapeutic outcomes.


U.S. Department Of Health And Human Services

Publication Date:



Rosenbaum, S., et al.

About the Author:

Center for Mental Health Services, Substance Abuse, and Mental Health Services Administration staff.

Recommended For:

This course is recommended for health care professionals, especially psychologists, counselors, social workers, and nurses who seek knowledge about the role private health plans play in determining medical necessity of behavioral health care. It is appropriate for all levels of participants’ knowledge.

Course Objectives:

  1. Become familiar with and be able to critique peer-reviewed and professional literature on medical necessity.

  2. Describe industry practices and judicial opinions that have examined decision-making procedures.

  3. Describe state insurance laws and the procedural elements of their independent review statutes.

  4. Identify relevant federal laws pertaining to medical necessity reviews.

Exam Questions

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Course Number: 101115
Credit Hours: 3cr
Exam Fee: $20.91
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Format: Online
4.22 out of 5
Popularity: 110 members have taken this course

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