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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

  • 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. 

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.

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.

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.
State/Contract Specific Criteria

Optum 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. 

Mental Health Parity and Addiction Equity Act

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:

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

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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