Evernorth^® Behavioral Health (Evernorth) periodically adopts and approves evidence-based behavioral clinical practice guidelines published by recognized professional practice societies. We schedule formal reapproval of the practice guidelines for updated and continued use at least every two years.¹ Prior to adoption, practice guidelines are assessed for consistency with MCG^TM Behavioral Health Guidelines.²

It is important to adhere to recognized guidelines when making clinical decisions to assure that the care authorized for acute and chronic behavioral health conditions meets national standards for excellence. As indicated in the Clinical Practice Guidelines,³ Evernorth uses the guidelines published by the American Psychiatric Association (APA⁴), the American Academy of Pediatrics, the Canadian Psychiatric Association, the National Institute on Alcohol and Alcoholism, the Centers for Disease Control and Prevention, and the American Society of Addiction Medicine. 

Additionally, Evernorth measures network performance against selected behavioral health practice guidelines annually.

Guideline distribution

To support clinical decision-making, we provide our behavioral staff with all adopted practice guidelines, as well as distribute them to contracted behavioral health care providers, using several methods:

• Annual email or mail-based communication.
• Letter to new providers.
• Behavioral Administrative Guidelines.
• Provider Newsroom.

Behavioral health medical necessity criteria and prior authorization
Our Behavioral Quality Committee approves behavioral health medical necessity criteria. These criteria are developed by analyzing evidence-based practice methods consistent with Evernorth’s Clinical Practice Guidelines for condition-specific management of illness. 

In determining responses to behavioral health service prior authorization requests, Evernorth uses the following guidelines:

• MCG^TM Behavioral Health Guidelines. 
• The ASAM Criteria^®.  
• LOCUS⁵ CALOCUS-CASII.⁶
• Our coverage policies.
• Evernorth Prior Authorization and Billing Resource Guide.
• State regulations.

Prior authorization requests are considered on a case-by-case basis and include an assessment of the availability of services in the local delivery system. 

We encourage you to access, review, and use the guidelines above as you develop care and treatment plans for your patients. For more information, refer to the Evernorth Medical Necessity Criteria.³

1  Our senior medical director may initiate more frequent action based on a semiannual review of new scientific evidence or changes in national standards and may recommend the adoption of additional guidelines within the two-year cycle, as appropriate.

2  On November 27, 2020, Evernorth Behavioral Health terminated use of its Standards and Guidelines/Medical Necessity Criteria for Treatment of Mental Health Disorders and transitioned to the MCG Behavioral Health Guidelines referenced above. The former archived Standards and Guidelines/Medical Necessity Criteria for Treatment of Mental Health Disorders are available for regulatory and reference purposes. This documentation will also be used throughout the duration of cases that were submitted prior to November 27, 2020. These cases include prior authorization requests, continued care requests/concurrent reviews, and appeals where the archived standards and guidelines document was used in initial determinations.

3  Available at the Evernorth Provider website (Provider.Evernorth.com).             

4  Links to the APA Clinical Practice Guidelines were updated in the 2024 Clinical Practice Guidelines Memo.

5  Level of Care Utilization System.

6  Child and Adolescent Level of Care/Service Intensity Utilization Instrument.