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

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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.

This course is based on the reading-based online, Medical Necessity in Private Health Plans: Implications for Behavioral Health Care created by Rosenbaum, S., et al. in 0.


U.S. Department Of Health And Human Services

Publication Date:


Course Material Author

Rosenbaum, S., et al.

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

Course Creator

Keith Gibson, Ph.D.

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.

Use our CE Approvals tool to look up your state requirements and how can help you meet them, or log in to your member account to show approvals relevant to your licensure.

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American Psychological Association (APA)

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CE Learning Systems is approved by the American Psychological Association to sponsor continuing education for psychologists. CE Learning Systems maintains responsibility for this program and its content.

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NAADAC, the Association for Addiction Professionals (NAADAC)

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Course Article

Exam Questions

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Course Retired
Course Number 101115
3 credit hours
Log in for credit hours relevant to your licensure.

  • Reading-Based Online
Exam Fee: No Longer Available
4.24 out of 5
116 members have taken this course