Use of LOCUS and CALOCUS/CASII for behavioral health medical necessity reviews
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This policy governs Aetna's adoption and use of the Level of Care Utilization System (LOCUS) and Child and Adolescent LOCUS/CASII (CALOCUS/CASII) to determine medical necessity for behavioral health services for Commercial plan members; it informs providers about the change and resources. It does not apply to substance use disorder reviews, which continue to use ASAM criteria.
Aetna will begin to utilize LOCUS and CALOCUS/CASII for determining medical necessity for behavioral health care, replacing LOCAT.
Coverage Criteria — LOCUS and CALOCUS/CASII Use
Application of LOCUS and CALOCUS/CASII
Aetna will apply these assessment tools when determining medical necessity for behavioral health services for affected members.
Effective adoption planned Q2 2021; Commercial plans specifically; Medicare Advantage uses CMS criteria.
SUD/chemical dependency exclusion
Exclusion for SUD:
Explicit exclusion in policy.
LOCUS and CALOCUS/CASII will not be used to determine medical necessity for substance use disorder/chemical dependency reviews. The policy retains the American Society of Addiction Medicine (ASAM) treatment criteria (Third Edition) as the standard for SUD/chemical dependency reviews except where state law explicitly requires the use of other criteria.
What Providers Must Do
LOCUS/CALOCUS/CASII required for medical necessity reviews
Aetna will begin to utilize the Level of Care Utilization System (LOCUS) and the Child and Adolescent LOCUS/Child and Adolescent Service Intensity Instrument (CALOCUS/CASII) to determine medical necessity for behavioral health care for members in Commercial plans; these tools will replace LOCAT for behavioral health reviews when implemented in Q2 2021.
Process continuity — review workflow unchanged
No significant change to the overall medical necessity review process is expected; however, the specific information requested during reviews may change.
Information and training resources
Providers may see changes in the information requested during medical necessity reviews and should consult available training and guidance resources for the assessment tools.
- LOCUS information: AACP website (see AACP for LOCUS)
- CALOCUS/CASII information: AACAP website (see AACAP for CALOCUS/CASII)
Denial risk from not using required assessment tools
After Aetna adopts LOCUS and CALOCUS/CASII for Commercial plan behavioral health reviews, failing to use these required assessment tools could result in reviews that are not aligned with Aetna's new medical necessity criteria.
Background
LOCUS and CALOCUS/CASII are standardized, person-centered assessment systems intended to match individual behavioral health needs to the appropriate level and intensity of services and to promote a common language among stakeholders. LOCUS was developed by the American Association for Community Psychiatry (AACP) and CALOCUS/CASII were developed jointly by AACP and the American Academy of Child and Adolescent Psychiatry (AACAP).
These instruments are used to inform medical necessity determinations and to help identify service gaps and project resource needs across populations and systems. Aetna will apply LOCUS and CALOCUS/CASII when determining medical necessity for behavioral health services for affected members, with implementation planned for Commercial plan members beginning in the second quarter of 2021.
Definitions
Application Across Levels of Care
LOCUS/CALOCUS/CASII apply across levels of behavioral health care as tools to determine appropriate level and intensity
Informational:
These tools describe the array of services to best meet needs of a population and help identify service gaps and resource needs.
Revision History & Material Changes
Aetna implemented use of LOCUS and CALOCUS/CASII for behavioral health medical necessity reviews for Commercial plan members, replacing LOCAT.
Planned adoption of LOCUS and CALOCUS/CASII announced for second quarter 2021 to determine medical necessity for behavioral health care.
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