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,, and to beneficiaries on the Optum website, Paper copies are available to providers and beneficiaries upon request.

Behavioral Clinical Policies
Best Practice Guidelines
Coverage Determination Guidelines
Credentialing Plans
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.

Psychological/Neuropsychological Testing Guidelines
Reimbursement Policies


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

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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