A General Look at 2023 Medical Necessity Criteria for Behavioral Health

How does Insurance determine Medical Necessity?

Many insurance carriers determine RTC/PHP/IOP authorization for care by utilizing medical necessity criteria to make determinations. The medical necessity criteria applied varies according to the behavioral health service being requested. To determine which criteria set will be used, general examples use the list below:

• Level of Care Utilization System (LOCUS) will be used to evaluate behavioral health treatment requests for adults age 19+ years.
• Child and Adolescent Level of Care Utilization System (CALOCUS) will be used to evaluate mental health treatment requests for children and adolescents ages 6-18 years.
• Early Childhood Service Intensity Instrument (ECSII) will be used to evaluate mental health treatment requests for infants, toddlers and children ages birth through 5 years.
• ASAM Criteria will be used to evaluate substance use disorder service and treatment requests
• New Directions medical policies apply to the following treatments and services, as applicable:
  • Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder (ABA for ASD)
  • Applied Behavior Analysis for the Treatment of Down Syndrome (ABA for DS)
  • Transcranial Magnetic Stimulation (TMS)
  • Electroconvulsive Therapy (ECT)
  • Psychological/Neuropsychological Testing (PNT)
  • 23-Hour Observation

LOCUS was developed by the American Association of Community Psychiatrists (AACP). CALOCUS was developed by AACP in collaboration with the American Academy of Child and Adolescent Psychiatry (AACAP). Both are maintained by Deerfield Solutions, LLC. ECSII was developed by AACAP. The ASAM Criteria was developed by the American Society of Addiction Medicine. New Directions administers each benefit as designed by the health plan and set out in the member’s benefit agreement. The presence of a specific level of care criteria within a criteria set does not constitute the existence of a specific benefit. Providers and facilities should verify the member’s available benefits online when available, or by contacting the applicable Customer Service department.

Access to LOCUS can be found by clicking here.

Access to CALOCUS can be found by clicking here.

Access to ECSII can be found by clicking on the following links:
ECSII Domains (Handout)
ECSII SI Definitions (Handout)
ESCII Manual 1.1 (Rev 4.2019) – QUICK REFERENCE ANCHOR POINT SHEETS INCLUDED

Access to the ASAM Criteria can be found by clicking here.

Specific policies or criteria set by insurance carriers in 2023. Insurance coverage and criteria can vary significantly depending on the insurance company, the specific plan, and the jurisdiction in which you reside. Insurance carriers often update their policies and criteria regularly.

However, we look can at some general information about the levels of care commonly seen in mental health treatment. These RTC/PHP/IOP levels of care may require varying criteria for insurance coverage:

1. Outpatient Care: This typically includes individual therapy, group therapy, counseling, and medication management provided on an outpatient basis. Patients may need a mental health diagnosis and recommendation from a healthcare professional to access this level of care.
2. Intensive Outpatient Program (IOP): IOP offers more structured and intensive treatment than traditional outpatient care. It may involve several hours of therapy and support services each day, usually for several days a week. Insurance carriers may require a mental health diagnosis and a treatment plan from a healthcare professional for coverage.
3. Partial Hospitalization Program (PHP): PHP provides a higher level of care than IOP. It involves full-day or nearly full-day treatment programs, usually provided in a hospital or specialized facility. PHP may be recommended for individuals who need more support but do not require 24-hour inpatient care. Insurance coverage may require medical necessity criteria and a treatment plan.
4. Inpatient Hospitalization: This level of care involves round-the-clock treatment in a hospital setting. It is typically reserved for individuals who are in crisis or at risk of harm to themselves or others. Insurance carriers often require a medical necessity determination and authorization for coverage.

The specific criteria for insurance coverage may include other factors for medical necessity, including severity of symptoms, risk of harm, and the recommendations of healthcare professionals.

What is the criteria for medical necessity using LOCUS assessment for RTC/PHP/IOP mental health?

The Level of Care Utilization System (LOCUS) is a tool used to assess the level of care needed for individuals with mental health and substance use disorders. It provides a framework for evaluating the severity of a person’s condition and determining the appropriate level of care, including Residential Treatment Centers (RTC), Partial Hospitalization Programs (PHP), and Intensive Outpatient Programs (IOP). While I can provide a general overview of the LOCUS assessment criteria, please note that the specific criteria and scoring may vary depending on the version and guidelines implemented by different organizations or jurisdictions. It’s always best to refer to the official documentation or guidelines provided by your healthcare provider or insurance carrier.

A look in detail of the LOCUS assessment of six different dimensions

Certainly! The Level of Care Utilization System (LOCUS) assessment evaluates individuals with mental health and substance use disorders across six different dimensions to determine the appropriate level of care. Here’s a detailed explanation of each dimension:

1. Risk of Harm: This dimension assesses the individual’s risk of harm to themselves or others due to their mental health condition. It considers factors such as the severity of suicidal ideation, presence of self-harm behaviors, risk of aggression, or violence. The assessment may include evaluating the frequency, intensity, and duration of these behaviors. A higher score in this dimension indicates a greater risk of harm and may indicate a need for a more intensive level of care.
2. Functional Status: This dimension focuses on the individual’s functional abilities and limitations. It evaluates their ability to perform activities of daily living, including self-care, work or school functioning, social functioning, and relationships. Impairments in these areas may indicate the need for a higher level of care. The assessment may consider factors such as the individual’s ability to maintain personal hygiene, manage finances, sustain employment or education, and engage in social interactions.
3. Medical, Addictive, and Psychiatric Co-Morbidity: This dimension assesses the presence of additional medical conditions, substance use disorders, or co-occurring psychiatric disorders that may impact the individual’s overall functioning and treatment needs. The assessment considers the severity and complexity of these co-morbid conditions, including their impact on physical health, mental health, and substance use. A higher score in this dimension indicates a greater need for comprehensive care that addresses these co-occurring conditions.
4. Recovery Environment: This dimension evaluates the individual’s living situation, support system, and access to resources that promote recovery. It considers factors such as stable housing, family support, availability of outpatient services, and involvement in the criminal justice system. The assessment examines the quality and stability of the individual’s recovery environment, including the level of support and resources available to them. A higher score in this dimension indicates a more supportive recovery environment and may influence the level of care recommended.
5. Treatment and Support History: This dimension examines the individual’s history of mental health and substance use treatment. It considers the effectiveness of past interventions, engagement in treatment, and adherence to medication regimens. The assessment may also evaluate the individual’s experience with different treatment modalities, such as therapy, medication management, or residential programs. A comprehensive understanding of the individual’s treatment history helps determine the most appropriate level of care and treatment interventions.
6. Engagement/Relapse Potential: This dimension assesses the individual’s motivation and ability to engage in treatment and their potential for relapse or non-compliance with recommended treatment. It considers factors such as the individual’s readiness for change, level of motivation, willingness to participate in treatment, and history of relapse or treatment non-compliance. A higher score in this dimension may indicate a need for a more structured and intensive level of care to support engagement and prevent relapse.

Each dimension is scored on a scale ranging from 0 to 4 or 0 to 5, with higher scores indicating a greater level of severity or need for care. The total scores across these dimensions are used to determine the appropriate level of care, such as Residential Treatment Centers (RTC), Partial Hospitalization Programs (PHP), or Intensive Outpatient Programs (IOP).

Specific guidelines and scoring criteria may vary depending on the version and guidelines implemented by different organizations or payers. There are other official LOCUS guidelines available online, or seeking guidance from a healthcare professional familiar with the assessment can help provide the most accurate and up-to-date information regarding the six dimensions of the LOCUS assessment.

A more specific model of what questions the LOCUS assessment requires to complete criteria

While I can provide a general overview of the dimensions assessed in the Level of Care Utilization System (LOCUS) assessment, I don’t have access to the exact questions or specific questionnaires used in the assessment. The LOCUS assessment is typically administered by trained professionals, such as mental health clinicians or care managers, who follow specific guidelines provided by the organization or jurisdiction implementing the assessment.

However, I can outline the general areas of inquiry that are typically covered in each dimension of the LOCUS assessment:

1. Risk of Harm:

• Inquire about suicidal ideation, intent, and plans.
• Assess for self-harm behaviors or risk of harm to others.
• Explore recent history of aggression or violence.

2. Functional Status:

• Evaluate the individual’s ability to perform activities of daily living, such as personal hygiene, dressing, and eating.
• Assess their work or school functioning, including attendance, productivity, and ability to carry out tasks.
• Examine social functioning, including relationships, social support, and engagement in social activities.

3. Medical, Addictive, and Psychiatric Co-Morbidity:

• Gather information about any medical conditions or physical health concerns.
• Assess the severity and impact of substance use disorders, including patterns of use, dependence, or withdrawal symptoms.
• Evaluate the presence and impact of co-occurring psychiatric disorders, such as anxiety, depression, or personality disorders.

4. Recovery Environment:

• Inquire about the individual’s living situation, stability of housing, and availability of a safe and supportive environment.
• Assess the presence and quality of social supports, including family, friends, or support groups.
• Evaluate the availability of outpatient services and resources that promote recovery, such as transportation or financial assistance.

5. Treatment and Support History:

• Gather information about previous mental health and substance use treatment experiences.
• Assess the effectiveness of past interventions and treatments.
• Evaluate the individual’s level of engagement and adherence to treatment plans, including medication management.

6. Engagement/Relapse Potential:

• Assess the individual’s motivation and readiness for change.
• Evaluate their willingness to participate in treatment and engage in therapeutic activities.
• Inquire about the individual’s history of relapse, treatment non-compliance, or difficulty sustaining recovery.

The questions and scoring criteria may vary based on the version and guidelines implemented by different insurance carriers.