Optum Clinical Criteria
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 used to make medical necessity 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 medical necessity determinations and placement decisions for adults ages 18 and older. LOCUS will be applicable in western states beginning on December 14, 2019 and the remaining states on January 31, 2020.
- Child and Adolescent Service Intensity Instrument (CASII): Standardized assessment tool developed by the American Academy of Child and Adolescent Psychiatry used to make medical necessity determinations and to provide level of service intensity recommendations for children and adolescents ages 6-18. CASII will be applicable in all states on January 31, 2020.
- Early Childhood Service Intensity Instrument (ECSII): Standardized assessment tool developed by the American Academy of Child and Adolescent Psychiatry used to make medical necessity determinations and to provide level of service intensity recommendations for children ages 0-5. ECSII will be applicable in all states on January 31, 2020.
- American Psychological Association Psychological and Neuropsychological Testing Billing and Coding Guide: Comprehensive billing and coding guide developed by the APA used for making medical necessity determinations for behavioral health psychological and neuropsychological testing services. Effective January 1, 2021.
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.
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.
National Best Practice Guidelines
- Clinical Practice Guidelines: Criteria that provide guidance about evidence-based practices adopted from nationally recognized entities such as by the American Psychiatric Association, and the American Academy of Child and Adolescent Psychiatry.
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 coverage determinations regarding proven or unproven services and treatments.
- Optum Coverage Determination Guidelines: Criteria that assist in interpreting and administering behavioral health benefits for Commercial benefit plans that don’t have a provision for medical necessity.
- Optum Psychological and Neuropsychological Testing Guidelines: Criteria used to make medical necessity determinations related to psychological and neuropsychological testing.
- Optum Electroconvulsive Therapy Supplemental Clinical Criteria: Criteria for ECT determinations.
- Optum Extended Outpatient Therapy Supplemental Clinical Criteria: Criteria for Extended Sessions determinations.
- Optum Quality Performance Tools: Quality tools that annually measure performance against at least two important aspects of each of two clinical practice guidelines to determine provider adherence. Performance measurement is related to the clinical process of care found within Optum’s clinical practice guidelines that is most likely to affect care.
Review, Dissemination and Use of Clinical Criteria
Optum behavioral health Clinical Criteria are available, unless proprietary, 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 when required and upon request. The Clinical Criteria and the procedures for applying them are reviewed and/or updated in accordance with Optum’s policies and contractual or regulatory requirements as appropriate. Optum behavioral health may develop Clinical Criteria that describe the generally accepted standards of practice evidence, prevailing standards and guidance supporting determinations made regarding specific services.
When deciding coverage, the member’s specific benefits must be referenced. All reviewers must first identify member eligibility, the member-specific benefit plan coverage, and any federal or state regulatory requirements that supersede the member’s benefits prior to using the Clinical Criteria. In the event that the requested service or procedure is limited or excluded from the benefit, is defined differently or there is otherwise a conflict between this guideline and the member’s specific benefit, the member’s specific benefit supersedes the Clinical Criteria.