Guidelines/Policies & Manuals
Overview: Clinical Criteria
Optum uses written 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 takes individual circumstances and the local delivery system into account when determining coverage of behavioral health services.
For mental health and wraparound services, Optum derives a standard set of clinical criteria from guidance produced by government sources, professional societies, and published research. Optum involves appropriate clinical staff, providers and consumers in developing, adopting, and reviewing its clinical criteria.
For substance-related disorder services, Optum standardly uses the ASAM Criteria to make coverage determinations.
Optum adopts and disseminates clinical practice guidelines relevant to its members for the provision of behavioral health services. The clinical practice guidelines adopted by Optum include those produced by the American Psychiatric Association, and the American Academy of Child and Adolescent Psychiatry.
Optum develops clinical criteria that supersedes its standard set or adopts externally-developed clinical criteria when required to do so by contract or regulation.
Optum annually reviews its clinical criteria and the procedures for applying them, and updates internally-developed clinical criteria when appropriate.
Optum’s clinical criteria are available to staff on Optum’s intranet site, to Optum practitioners on the Optum website, www.providerexpress.com, and to beneficiaries on the Optum website, www.liveandworkwell.com. Paper copies are available to providers and beneficiaries upon request.
- Accelerated Resolution Therapy (ART)
- Chemical Aversion Therapy
- Complementary and Alternative Medicine (CAM) Treatments
- Computer Based Treatment for Cognitive Behavioral Therapy (CBTCBT)
- Cranial Electrotherapy Stimulation
- Electroconvulsive Therapy (ECT)
- Extended Outpatient Psychotherapy
- Applied Behavior Analysis for Autism Spectrum Disorders
- Ketamine Infusions
- Office-Based Opioid Treatment (OBOT)
- Opioid Treatment Program (Maintenance Therapy)
- Sexual Conversion Therapy
- Teaching Family Model
- Transcranial Magnetic Stimulation
- Ultrarapid Detoxification
- Wilderness Therapy
Optum's Coverage Determination Guidelines are intended to standardize the interpretation and application of terms of the Member's Benefit Plan including terms of coverage, Benefit Plan exclusions and limitations.
Intellectual Disability (Mental Retardation)
Judicial or Administrative Proceedings or Orders (aka Court Ordered Treatment)
Neurocognitive Disorders (Dementia)
- Optum Level of Care Guidelines
- California Medi-Cal (Medicaid)
- Connecticut Intensive In-Home Services
- Florida Level of Care Guidelines (Medicaid)
- HI Intensive Behavioral Therapy/Applied Behavioral Analysis
- Idaho Level of Care Guidelines (Medicaid)
- Indiana (Commercial)
- Iowa Medicaid Level of Care Guidelines
- Kansas (Medicaid)
- Louisiana Level of Care Guidelines (Medicaid)
- Minnesota Medicaid
- Mississippi Leve of Care Guidelines (Medicaid)
- Missouri Medicaid
- Nebraska Medicaid Level of Care Guidelines
- New Jersey Medicaid Level of Care Guidelines
- New York Medicaid
- Ohio (Medicaid)
- OH Assertive Community Treatment
- OH Behavioral Health Nursing
- OH Children’s Intensive Behavioral Services
- OH Common Service Criteria
- OH Community Psychiatric Support Treatment
- OH Crisis Intervention
- OH Day Treatment
- OH Individualized Placement & Support/Supported Employment
- OH Inpatient & Institutions for Mental Disease
- OH Intensive Home Based Services
- OH Outpatient Services
- OH Peer Recovery Support
- OH Psychological & Neuropsychological Testing
- OH Psychosocial Rehabilitation
- OH Therapeutic Behavioral Services
- Rhode Island Medicaid Level of Care Guidelines
- Texas UM Guidelines:
- Virginia Level of Care Guidelines (Medicaid)
VA Behavioral Therapy Services Under EPSDT
VA Day Treatment/Partial Hospital
VA Mental Health Case Management
VA Psychosocial Rehabilitation
VA Therapeutic Day Treatment
- Wisconsin Day Treatment Guidelines
- Washington Integrated Managed Care Medicaid Level of Care Guidelines
*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.
- 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
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:
- Optum Summary of MHPAEA Final Rules
- 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
The following is a typical summary of the processes, strategies, evidentiary standards, and other factors that may be used to apply benefit plan terms and conditions (also known as non-quantitative treatment limitations) with respect to mental health/substance use disorder benefits. However, the mental health/substance use disorder non-quantitative treatment limitations will vary based on the specific requirements of the member’s medical/surgical plan.
A comparable summary for the member's medical benefits may be available from the member's medical plan.
- Members of a UnitedHealthcare medical plan can access their summary online at the United for Reform Resource Center.
- HI Addendum
- HPHC Addendum
- IA Medicaid Manual Addendum
- KS KanCare Administrative Guide (Chapter 6)
- Maryland National Manual Addendum
- MA - AllWays Health Partners Provider Manual Addendum
- MO Medicaid Manual BH Addendum
- MS CAN Manual
- NJ MLTSS Manual Addendum
- NY Medicaid Behavioral Health Provider Manual
- PA Manual Addendum
- RI Appendices
- TX Addendum
- TX CHIP Manual
- TX STAR Kids Manual
- TX STAR Manual
- TX STAR+PLUS Manual
- VA UnitedHealthcare Community Plan, a CCC Plus Plan
- WA Medicaid Addendum
- WA IMC UnitedHealthcare Community Plan 2019 Manual
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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