Guidelines/Policies & Manuals

Guidelines/Policies

Behavioral Clinical Policies
Best Practice Guidelines
Coverage Determination Guidelines

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.

Anorexia Nervosa

Attention-Deficit/Hyperactivity Disorder (ADHD)

Autism Spectrum Disorders

Binge Eating Disorder

Bipolar and Related Disorders

Bulimia Nervosa

Conduct Disorders

Custodial Care and Inpatient & Residential Services

Depressive Disorders

Dissociative Identity Disorders  

Drug Testing

Gambling Disorder

Gender Dysphoria

Generalized Anxiety Disorder (GAD)

Health & Behavior Assessment and Intervention

Home-Based Outpatient Treatment

Impulse Control Disorders

Intellectual Disability (Mental Retardation)

Judicial or Administrative Proceedings or Orders (aka Court Ordered Treatment)

Motor Disorders

Neurocognitive Disorders (Dementia)

Obsessive Compulsive Disorder

Opioid Dependence, Office-Based Treatment of

Opioid Treatment Program (Methadone Maintenance)

Oppositional Defiant Disorder (ODD)

Other and Unspecified Disorders  

Other Conditions That May Be a Focus of Clinical Attention (V-Codes)

Panic Disorder

Personality Disorders

Proven and Unproven Services

Psychological and Neuropsychological Testing

Schizophrenia and Schizoaffective Disorder

School-Based Services for Children and Adolescents

Specific Learning Disorder

Specific Phobias

Substance-Related and Addictive Disorders

Telemental Health

Transcranial Magnetic Stimulation (TMS)

Trauma & Stressor Related Disorders

Credentialing Plans
Level of Care Guidelines

Iowa 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.

Medicare Coverage Summaries
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

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.

Optum Guideline Evidence Base
Psychological/Neuropsychological Testing Guidelines
Reimbursement Policies

Manuals

Network Manual
State-Specific Manuals and Addendums
Disability Solutions Program
Massachusetts Emergency Service Program (ESP)
Senior Services Resource Guide

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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