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Clinical Practice Guidelines



HEDIS is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis. Health plans also use HEDIS results themselves to see where they need to focus their improvement efforts.


Utilization Management Medical Necessity Criteria

DWIHN uses nationally recognized medical necessity criteria from MCG to assist in making behavioral health utilization management decisions. The criteria are reviewed annually with input from practitioners in our network. Access to the on-line version of the criteria is provided to all contracted providers/practitioners or by means of CD for those providers/practitioners with no access to the internet. 

ASAM criteria is utilized for all substance use disorder decisions.  The ASAM Criteria, Third Edition, is copyrighted but can be purchased by contacting:

American Society of Addiction Medicine
4601 North Park Ave
Upper Arcade Suite 101
Chevy Chase, MD 20815
Telephone: (301) 656-3920 Fax: (301) 656-3815
DWIHN shall provide specific medical necessity criteria to practitioners/providers and enrollees/members and other stakeholders upon request free of charge. Criteria can be requested to be provided by email, fax, mail, in-person or by telephone by calling (888) 490-9698.

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