Clinical Criteria and Guidelines
Clinical Criteria based on sound clinical evidence
Optum behavioral health uses Clinical Criteria based on sound clinical evidence to make coverage determinations, as well as to inform discussions about evidence-based practices and discharge planning. In using its Clinical Criteria, Optum Behavioral Health takes individual circumstances and the local delivery system into account when determining coverage of behavioral health services. The following are the Clinical Criteria used by Optum Behavioral Health to make coverage decisions. Please note other Clinical Criteria may apply outside of or in addition to the following criteria due to superseding federal or state requirements, and/or specific contractual requirements.
Externally Adopted Clinical Criteria
- American Society of Addiction Medicine (ASAM) Criteria®, Third Edition: Criteria developed by the American Society of Addiction Medicine used to make determinations for substance-related disorder benefits.
- Level of Care Utilization System (LOCUS): Standardized level of care assessment tool developed by the American Association of Community Psychiatrists used to make determinations and placement decisions for adults ages 18 and older.
- Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII): Standardized assessment tool developed by the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists used to make determinations and to provide level of service intensity recommendations for children and adolescents ages 6-18.
- Early Childhood Service Intensity Instrument (ECSII): Standardized assessment tool developed by the American Academy of Child and Adolescent Psychiatry used to make determinations and to provide level of service intensity recommendations for children ages 0-5.
- American Psychological Association Psychological and Neuropsychological Testing Billing and Coding Guide: Comprehensive billing and coding guide developed by the APA used for making determinations for behavioral health psychological and neuropsychological testing services.
Medicare Required Clinical Criteria
- Centers for Medicaid and Medicare (CMS) National and Local Coverage Determinations (NCDs/LCDs): Criteria used to make medical necessity determinations for Medicare benefits.
- Alcohol and Substance Abuse Treatment
- Health and Behavior Assessment & Intervention
- Hemodialysis for the Treatment of Schizophrenia – Non-Coverage Summary
- Home Health Psychiatric Care
- Outpatient Services
- Psychiatric Inpatient Hospitalization
- Psychiatric Partial Hospitalization
- Psychological and Neuropsychological Testing
- Transcranial Magnetic Stimulation (TMS)
- Vagus Nerve Stimulation (VNS) for Treatment Resistant/Intractable Depression – Non-Coverage Summary
Optum National Behavioral Health Clinical Criteria
- Optum Behavioral Clinical Policies: Criteria that stem from evaluation of new services or treatments or new applications of existing services or treatments and are used to make determinations regarding proven or unproven services and treatments.
- Optum Psychological and Neuropsychological Testing Guidelines: Criteria used to make determinations related to psychological and neuropsychological testing.
- 2019 Psychological and Neuropsychological Testing Billing and Coding Guide
- Optum Psychological and Neuropsychological Testing - Supplemental Clinical Criteria
- For Ohio Medicaid please apply the Ohio State-Specific Medicaid Supplemental Clinical Criteria found at: https://www.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/optumLOCG/ohlocg/ohMedcadLOCG.pdf
- Supplemental Clinical Criteria: Optum developed criteria for additional services.
State/Contract Specific Clinical Criteria
- State-Specific Supplemental Clinical Criteria: State or contract specific Criteria used to make medical necessity determinations for mental health disorder benefits when there are explicit mandates or contractual requirements outside of the Criteria above.
Optum Clinical Criteria
- AZ Medicaid Supplemental Clinical Criteria
- California Medi-Cal (Medicaid)
- Florida Medicaid Supplemental Clinical Criteria
- HI Intensive Behavioral Therapy/Applied Behavioral Analysis
- Idaho Supplemental Clinical Criteria
- Illinois Supplemental Clinical Criteria
- Indiana Medicaid Supplemental Clinical Criteria: Drug Testing
- Kansas Medicaid Supplemental Clinical Criteria
- Kentucky Medicaid Supplemental Clinical Criteria
- Louisiana Supplemental Clinical Criteria
- Louisiana Medicaid Applied Behavior Analysis
- Minnesota Medicaid
- Mississippi Medicaid Supplemental Clinical Criteria (Medicaid)
- Missouri Medicaid
- Nebraska Medicaid Supplemental Clinical Criteria
- New Jersey Medicaid Supplemental Clinical Criteria
- New York Medicaid
- North Carolina Medicaid Supplemental Clinical Criteria
- Ohio (Medicaid)
- Rhode Island Medicaid Supplemental Clinical Criteria
- Tennessee Medicaid
- Virginia Medicaid Supplemental Clinical Criteria
- Wisconsin Day Treatment Guidelines
- Washington Integrated Managed Care Medicaid Supplemental Clinical Criteria
*The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.
The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires that benefits for mental health and substance use disorders (MH/SUD) be provided and administered in a fashion that is no more restrictive than the manner in which medical/surgical benefits are provided.
The Final Rules for MHPAEA were released on November 13, 2013 and apply to most plans as they renew on or after July 1, 2014.
For more information on MHPAEA:
- MHPAEA Final Rules
- The Center for Consumer Information & Insurance Oversight MHPAEA Fact Sheet
- Department of Labor MHPAEA Fact Sheet
The member’s medical plan and Optum have worked together to comply with Federal Mental Health Parity. Members have access to their plan documents (e.g., Certificate of Coverage or Summary Plan Description) as well as the medical necessity and coverage determination guidelines for both medical/surgical and mental health/substance use disorder benefits. You and the member also have access to detailed information regarding Optum’s Guidelines/Policies & Manuals related to mental health/substance use disorder benefits
- Members of a UnitedHealthcare medical plan can access their summary online at the United for Reform Resource Center.
Note: Optum policies may use CPT, HCPCS, specialty society edit standards, or other coding methodologies from time to time. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement.
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