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.
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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