Clinical Necessity Reviews
Health Net Federal Services, LLC (HNFS) is required to perform clinical necessity reviews on all treatment plans before authorizing treatment. We staff qualified, clinical reviewers (BCBAs, BCBA-Ds) to complete the review and make sure the treatment plan coincides with the most appropriate level of care for the beneficiary.
During a clinical necessity review, we evaluate the request for:
- A complete treatment plan
- Outcome measure scores*
- Level of clinical support
- Duration of services
- Location of services, if applicable (such as school, community)
- Goals and recommendations
- Services requested that need to be revised or removed (such as services not covered under the ACD)
*Note: The PSI-4 and SIPA outcome measures are standardized, reliable measures of stress and family dynamics that help to identify where additional support resources may benefit both the family and the beneficiary. The PSI-4 and the SIPA stress indexes and scores are not factors for treatment planning or coverage determination.
What Is the Process?
Clinical necessity reviews begin once we have received a complete treatment authorization request from the applied behavior analysis (ABA) provider and all program requirements are met (eligibility, outcome measures, two-year referral, etc.).
- It takes HNFS up to five business days to complete the review.
- In some cases, clinical reviewers may request additional information and/or a consultation with the ABA supervisor to discuss elements of the treatment plan.
- After the review and (if applicable) consultation is complete, we will either authorize ABA services or request the provider submit an updated treatment plan for further review.
- If the provider needs to submit an updated treatment plan, we will restart the clinical necessity review process once we get the requested information.
Note: We will send you a copy of any additional information requests we issue to the ABA provider. If you have questions, please reach out to the ABA provider about these requests.