About Criteria Status
In a medical review, evaluating criteria determines the criteria status as follows:
- Criteria Met— Indicates that criteria for medical necessity has been met.
- Criteria Not Met— Indicates that criteria for medical necessity has not been met.
Decision Tree Criteria Status
In products that display the criteria in decision-tree format, the status may be Criteria Met or Criteria Not Met. However, certain subsets have the following Met status:
Level of Care: Acute Adult subsets
The met indicator displays the following level of care that is met for the review:
- Observation Met
- Acute Met
- Intermediate Met
- Critical Met
- Hospital in the Home Met
Level of Care: Acute Pediatric subsets
The met indicator displays the following level of care that is met for the review:
- Observation Met
- Acute Met
- Intermediate Met
- Critical Met
- Transitional Care Met
- Newborn Level I Met
- Special Care Level II Met
- Neonatal Intensive Care Level III Met
- Neonatal Intensive Care Level IV Met
Subacute & Skilled Nursing
- Subacute Met
- SNF Met
Behavioral Health
The met indicator displays the level of care that is met for the review. Behavioral Health criteria have the following met indicators:
- Inpatient Met
- Inpatient Detoxification Met
- Inpatient Rehabilitation Met
- Day Treatment Program Met
- Behavioral Health Observation Met
- Residential Crisis Program Met
- Residential Treatment Center Met
- Subacute Care Met
- Supervised Living Met
- Partial Hospital Program Met
- Home Care Met
- Intensive Community-Based Treatment Met
- Intensive Outpatient Program Met
- Outpatient Met