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CurrentBeacon-Health-OptionsPolicy N/A

Behavioral health medical necessity criteria (Massachusetts)

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Defines Carelon Behavioral Health's medical necessity criteria for inpatient and diversionary behavioral health services (psychiatric and substance use) applicable to Massachusetts members and providers using Carelon/Baycon standards and referenced external criteria (InterQual, ASAM, CMS).

Policy Summary

PayerBeacon-Health-Options

PolicyBehavioral health medical necessity criteria (Massachusetts)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateFeb 15, 2026

Last ReviewFeb 15, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests only after confirming member meets the listed medical necessity admission criteria and include required assessments and documentation (e.g., DSM-5-TR diagnosis, CANS/CRAFFT where applicable, ABA assessment details).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

annualcriteria review frequency

6distinct service sections

45ABA assessment window (days)

<19TCU age limit

120CSP-HI billing window (days)

Coverage and Medical Necessity Criteria

Continuation Therapy

ALL of the following

The member's condition continues to meet admission criteria for the service level as defined in the relevant admission criteria;
There is documented progress toward the treatment plan goals, but goals have not yet been substantially achieved (objective measures or data are present to demonstrate incremental improvement);
If progress is not evident, the treatment plan has been reviewed and revised with specific, documented changes intended to address barriers to improvement;
Care is being delivered in a clinically appropriate manner with frequency and intensity matched to the member's current symptoms and functional needs;

Policy Summary

PayerBeacon-Health-Options

PolicyBehavioral health medical necessity criteria (Massachusetts)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateFeb 15, 2026

Last ReviewFeb 15, 2026

Next Review DateN/A

SourceLink

On This Page

Referenced Codes and Coding Guidance

Referenced external coverage/code sourcesmixed

No codes listed

Referenced coverage guidancemixed

CMS LCD L33626

Psychiatric Partial Hospitalization Programs (Medicare only)

No codes listed in this excerptmixed

No codes listed

Referenced NCD/LCD identifiers and policy referencesmixed

130.2	CMS NCD Outpatient Hospital Services for Treatment of Alcoholism (Medicare only)
130.5	CMS NCD Alcohol and Drug Abuse Treatment Services in a Freestanding Clinic (Medicare only)
130.6	CMS NCD Outpatient Treatment of Drug Abuse (Chemical Dependency) (Medicare only)
130.7	CMS NCD Outpatient Hospital Withdrawal Treatments for Narcotic Addictions (Medicare only)
L33632	CMS LCD Psychiatry and Psychology Services (Medicare only)

inv-96: TCU expected transition timeline

Expected transition timeframe30 days or less

PopulationYouth in DCF custody who no longer meet inpatient criteria but need transition support

PurposeFacilitate transition to home, foster care, group home, or residential placement

inv-98: ABA assessment completion window

Completion windowWithin 45 calendar days of initial assessment authorization

Maximum assessment durationUp to 12 hours of direct and indirect assessment

PurposeInform initial ABA treatment plan with at least two direct observations and standardized measures

inv-99: Utilization threshold for additional review

Utilization review triggerLess than 75% utilization of approved direct service hours across at least one complete review cycle may trigger additional review

Mitigation expectationLow utilization alone does not establish lack of medical necessity; document barriers and mitigation efforts

Related requirementContinued authorization requests must document interventions to address adherence barriers

inv-100: Recent 24-hour behavioral health discharge lookback

Recent 24-hour discharge lookbackWithin past 180 days

Programs referencing this lookbackRSN, CSP admission and related diversionary criteria

UseIdentifies transition/risk factor for eligibility to community support/navigation services

inv-101: Multiple acute encounters lookback

Multiple acute encounter lookbackWithin past 90 days

Encounter typesAMCI, YMCI, ED, Community Crisis Stabilization, restoration center contacts

UseCounts as risk indicator for RSN/CSP admission criteria

inv-102: Recovery Coach minimum contact frequency

Minimum contact frequencyAt least one contact every 21 days

ContextRequired for Recovery Coach continued stay and engagement measurement

ConsequenceFewer than one contact every 21 days may lead to discharge/denial of continued authorization

inv-103: Frequent ED/acute use thresholds for CSP-HI eligibility

Frequent ED/acute use thresholds4+ ED visits in past 12 months OR 3+ acute/psychiatric inpatient admissions in past 12 months

Program relevanceUsed for CSP-HI housing-status eligibility (housing-related criterion)

Alternate lookbackRepeated ED use also defined as 2+ visits within 6 months for some HNBC contexts

inv-104: CSP-HI pre-housing billing window

Pre-housing billing windowUp to 120 days before move-in

Billing continuationOnce housed, billing may continue until Plan determines CSP-HI no longer medically necessary

Required conditionIdentified PSH opportunity and move within 120 days or homeless medical respite with PSH plan

inv-105: Frequent ED use definition for HNBC

Frequent ED use definitionFour or more ED visits within the past 12 months (or two or more within six months per HNBC definition)

Source contextsUsed in CSP-HI housing status and HNBC repeated ED use criteria

ApplicationCounts toward homelessness/health-needs criteria when assessing CSP eligibility

inv-97: Placeholder key/value (no label provided)

PlaceholderNo content provided in brief or source

NoteThis key/value was included as a placeholder in the layout; no authoritative value available to populate

ActionConfirm source or brief entry to replace placeholder

Actions, Prior Authorization, Documentation and Billing

Prior Authorization

Criteria source and prior-auth guidance — hierarchy and references

Prior authorization, eligibility, documentation, and provider actions are governed by the Medical Necessity Criteria (MNC) hierarchy and program-specific rules. Carelon Behavioral Health's MNC are reviewed at least annually by the Corporate Quality Medical Management Committee. To determine applicable criteria, providers must follow the hierarchy: 1) CMS NCD/LCD for Medicare members; 2) Relevant custom MNC when CMS criteria do not apply; 3) For SUD-related care, ASAM criteria when no custom criteria exist; 4) InterQual Behavioral Health Criteria for non-SUD levels of care when no custom criteria exist; and 5) Carelon national MNC if none of the above apply. InterQual Behavioral Health Criteria are accessible through the Carelon website. Providers must consult the applicable MNC source when preparing authorizations or documentation.

Follow CMS NCD/LCD first for Medicare members
Use custom MNC when available for non-Medicare members
Use ASAM for SUD care when no custom criteria exist
Use InterQual for non-SUD levels of care when appropriate
Carelon national MNC is the final fallback

Prior Authorization

Authorization requires meeting listed MNC

Authorizations for all levels of care require documentation demonstrating the member meets the listed medical necessity criteria (MNC) for that specific service. Requests must include the required assessments, risk/safety plans, and treatment plan elements specified in the applicable service chapter. Absent documentation that all required MNC elements are met, prior authorization/continued stay requests may be denied or returned for additional information.

Authorization requires meeting ALL listed MNC for the requested level of care
Include supporting assessments and treatment plans with requests
Incomplete documentation may result in denial or delay

Prior Authorization

ICC prior authorization/eligibility (Commercial)

Intensive Care Coordination (ICC) available to Commercial members requires prior authorization/eligibility verification for commercial lines. For commercial members, ICC criteria #1-6 must all be met (youth <19, DSM-5-TR/ICD diagnosis, SED criteria, service needs, voluntary consent, etc.). Providers must document CANS-MA/CRAFFT/SNCD and the Individual Care Plan (ICP) development and CPT activity as part of authorization requests.

ICC (Commercial) requires documentation that Criteria 1-6 are all met
Include CANS-MA, CRAFFT (if applicable), SNCD and ICP documentation
Document CPT meetings, care planning and consent for authorization

Prior Authorization

Prior authorization for EIBI assessment

Early Intensive Behavioral Intervention (EIBI) assessment for children under age three may require prior authorization. Providers should obtain PA for assessment when required; in most cases EIBIs may request authorization for assessment prior to family selection of a specific provider. Documentation must include ASD diagnosis confirmation and assessment elements described in the EIBI admission criteria.

EIBI assessment may require prior authorization — obtain PA per program rules
Assessment PA can often be requested before family selects a provider
Include confirmed ASD diagnosis and evidence-based diagnostic tool results

Prior Authorization

PACT eligibility and program requirement

Program of Assertive Community Treatment (PACT) eligibility requires meeting all program admission criteria. Providers must verify adult age (19+), Medicaid/DMH eligibility as applicable, DSM-5-TR psychiatric diagnosis, significant functional impairments, indicators of continuous high-service need, and willingness to accept PACT team services prior to enrollment/authorization.

PACT admission requires adult age (19+), relevant eligibility, DSM-5-TR diagnosis
Must document significant functional impairments and indicators of high-service need
Member and guardian (if applicable) must consent to and cooperate with PACT

Denial Risk

Admissions exclusively for bed availability

Acute, High-Intensity Inpatient admissions must not be authorized solely for bed availability. Providers must document that the member meets admission criteria for the specialized level and that admission is clinically indicated for safety/stabilization rather than inpatient bed access.

Admissions exclusively for bed availability are excluded — do not request authorization for this reason
Document clinical justification that meets High-Intensity admission criteria

Denial Risk

TCU exclusion triggers

Transitional Care Unit (TCU) exclusions — any one of the listed exclusion criteria is sufficient to exclude admission. Verify voluntary guardian consent, absence of imminent risk requiring higher level of care, and appropriateness regarding medical/developmental conditions and intended placement; lack of consent or imminent risk necessitates denial.

TCU exclusion triggers: imminent risk to self/others, lack of guardian consent, complex medical/developmental conditions, or planned placement to a more-intensive long-term program
Do not authorize TCU if any exclusion applies

Denial Risk

Co-Occurring Enhanced RRS exclusion triggers

Co-Occurring Enhanced RRS admissions require documentation of ASAM-based assessment, dual diagnosis (SUD plus moderate-to-severe mental health condition), need for small milieu/high staff ratio, medication evaluation needs, and recent high service utilization (e.g., inpatient hospitalization or multiple ED/MCI visits within three months). Failure to document these elements may trigger exclusion or denial.

Document ASAM 6-dimension assessment and evidence of co-occurring SUD and moderate-to-severe mental health disorder
Provide recent service utilization evidence (inpatient, ED/MCI events) within past 3 months

Denial Risk

FS&T exclusion for poor prognosis

Family Support & Training (FS&T) exclusion: if there is impairment with no reasonable expectation of progress toward identified treatment goals for this service, the member may be excluded. Providers must document prognosis and treatment expectation when requesting FS&T authorization.

FS&T exclusion for poor prognosis — document expectation of progress
FS&T is available only to eligible MassHealth members under age 21

Denial Risk

ICC consent and placement exclusions

ICC consent and placement exclusions — ICC requires voluntary consent from the person(s) authorized to consent to medical treatment. ICC is not appropriate if youth are in placements that preclude ICC goals or when consent is not obtained. Placement and capacity issues that prevent ICP development or CPT participation must be documented and will result in exclusion.

ICC requires voluntary guardian consent for participation
Inappropriate placement or lack of consent are exclusion triggers

Denial Risk

IHT / IHBS safety and placement exclusions

IHT / IHBS safety and placement exclusions — services must not be delivered when the service environment presents a serious safety risk to providers, when the youth is not in or returning to a family home, or when medical conditions prevent benefit. IHBS expressly excludes concurrent delivery with ABA; do not authorize concurrent IHBS and ABA.

Exclude IHT/IHBS when service setting is unsafe for providers or member has medical/developmental conditions preventing benefit
IHBS cannot be provided concurrently with ABA — authorization must reflect this

Denial Risk

No concurrent IHBS and ABA

No concurrent IHBS and ABA — authorization systems and treatment plans must not approve or bill for IHBS and ABA services provided concurrently to the same member. Providers must choose the clinically most appropriate intervention and document why concurrent services are not indicated.

Concurrent IHBS and ABA is expressly excluded
Document rationale if switching between services is clinically indicated

Step Therapy

FIT Sequencing and Concurrency — FIT indicated after less-intensive services fail

Family-based Intensive Treatment (FIT) sequencing and exclusion triggers — FIT is indicated after less-intensive outpatient/IHT/ICC services have been tried and found insufficient. FIT cannot be provided concurrently with IHT/FS&T/ICC (except where clinical guidance allows and documentation supports safe concurrency). Required consent and recent triage/admission history (e.g., recent 24-hour level of care or YMCI/ED evaluation) must be present. Lack of required triage or recent higher-level service contact is an exclusion.

FIT requires prior attempts at less-intensive services and recent triage/admission evidence
Exclude if required consent not obtained or concurrent incompatible services are active
FIT sequencing: must document prior services and rationale for step-up

Prior Authorization

Prior Authorization for Emergency Services — emergency services accessible without prior authorization

Mobile Crisis (AMCI/YMCI) exclusions and emergency authorization — mobile crisis services require consent for evaluation; refusal of consent is an exclusion. Emergency services (including YMCI/AMCI) are accessible without prior authorization; however, when an emergency admission is necessary, contracted facilities should notify Carelon with clinical information as close to admission as possible and no later than 24 hours. For commercial members, screening by a qualified behavioral health professional from the ED or AMCI/YMCI is required.

Emergency services do not require prior authorization — notify Carelon within 24 hours of emergency admissions
Consent refusal for mobile crisis evaluation is an exclusion
Commercial members require screening by a qualified BH professional

Note

YMCI service delivery — 24/7 availability and no prior auth for crisis response

YMCI service delivery requirements — YMCI must be available 24/7/365, provide up to seven days of crisis intervention/stabilization, perform face-to-face evaluations when required, and do not require prior authorization for crisis response. Admission to YMCI requires that phone triage attempts were insufficient and at least one high-risk criterion be present. Consent refusal excludes service.

YMCI available 24/7/365 and provides up to 7 days of services
No prior authorization required for crisis response; document triage attempts
Consent refusal excludes YMCI evaluation

Prior Authorization

ABA initial assessment and treatment authorization requirements

ABA initial assessment and treatment authorization requirements — For ABA (Commercial), initial assessment authorization requires the member be under 21 with confirmed ASD or Down Syndrome diagnosis; assessment and initial treatment authorizations must include comprehensive diagnostic documentation, medical screening, and multidisciplinary evidence as described. Initial treatment authorization requires parent/guardian consent, an initial treatment plan, and evidence that ABA will reduce functional deficits or safety risks.

ABA assessment: member <21, confirmed ASD/Down Syndrome, multidisciplinary documentation
Initial treatment: guardian consent, initial treatment plan, measurable functional goals

Prior Authorization

Prior authorization for EIBI assessment

Prior authorization for EIBI assessment — EIBI admission for children under three requires referral from Early Intervention (EIP), confirmation of ASD diagnosis, and, if required, prior authorization for assessment. Providers are encouraged to request assessment authorization promptly so services can begin as soon as possible.

EIBI assessment may require PA; referral from EIP required
Confirm ASD diagnosis preferably with evidence-based diagnostic tools

Denial Risk

Service may be excluded if member is at acute risk or lacks consent; Denial or exclusion may be triggered if documentation missing or duplicate services present

Denial or exclusion triggers and safety-based exclusions — Services may be excluded or denied when the member is at acute/imminent risk to self or others requiring a higher level of care, when medical contraindications exist, when consent is not obtained, or when services would duplicate existing supportive services. Psychiatric consultation on medical units should be limited to clinically necessary consults; if safe maintenance without psychiatry is possible, consult may be excluded.

Exclude/deny if acute/imminent risk requires more-intensive care
Exclude/deny if required consent is not obtained
Exclude/deny when services are duplicative of existing supports
Psychiatric consults excluded when member can be safely maintained without consultation

Documentation Required

Required clinical assessments and documentation

Required clinical assessments and documentation — For admission and authorization across programs, providers must supply DSM-5-TR/ICD diagnoses, ASAM or InterQual assessments as applicable, treatment plans (ICP or ABA plan), CANS/MA CANS, CRAFFT (for youth 12+), Functional Behavior Assessment where indicated, safety/risk plans, and documentation of community supports being inadequate. Emergency admissions require notification to Carelon within 24 hours.

DSM-5-TR/ICD diagnosis required in admission documentation
ASAM, InterQual, CANS/MA CANS, CRAFFT, Functional Behavior Assessment as applicable
Treatment plans (ICP, ABA treatment plan) and risk/safety plans must be submitted
Document that community supports are inadequate when required by level of care
Emergency admissions: notify Carelon within 24 hours with clinical information

Documentation Required

Required assessment and linkage to treatment plan

Required assessments and linkage to treatment plan — Assessments (e.g., MA CANS, CRAFFT, Functional Behavior Assessment) must be linked explicitly to individualized treatment plan goals. ICC and CSP require documented coordination activities, CPT minutes, ICP development, and evidence of active linkage to services. Lack of linkage or missing assessment elements may delay or deny authorization.

Link assessment findings directly to treatment plan goals and objectives
Include CPT documentation, ICP content, and coordination activities for ICC
CSP service plans must document individualized goals and linkages to clinical treatment

Documentation Required

Required Assessments and Treatment Plan Goals

Required Assessments and Treatment Plan Goals — Treatment plans must contain specific, measurable, observable goals (e.g., ABA goals, ICP objectives) with progress metrics, data collection methods (behavioral graphs, session notes), and plans for generalization and maintenance. ABA plans must specify LABA vs. technician hours, supervision, and parent/caregiver training. Treatment plans should be updated at required intervals (e.g., ABA every six months).

ABA: specify LABA vs technician hours, supervision, and parent training
Include measurable objectives, data collection (graphs, session notes) and generalization plans
Update treatment plans per program rules (e.g., ABA plan updates at least every 6 months)

Documentation Required

CPS and ABA require documentation of activities/supports, coordination, and treatment plan elements

CPS and ABA documentation requirements — Certified Peer Specialist (CPS) activities must be documented (face-to-face, telephonic, collateral contacts), and ABA documentation must include direct/indirect treatment summaries, progress data, utilization rates, and parent/caregiver involvement. For ABA initial authorization, include complete summary of recommended direct/indirect hours and clinical justification.

CPS: document all supportive activities and coordination, including discharge planning
ABA: include direct/indirect hour breakdown, supervision plan, and data demonstrating progress
Low utilization (<75%) of authorized direct ABA hours may prompt review — document barriers and mitigation

Prior Authorization

Initial authorization requests must include required content

Initial authorization requests must include required content — For ABA this means LABA vs technician hours, supervision schedule, parent/caregiver training, treatment goals, and setting rationale. ICC/ICP authorizations must include assessment, CPT activity, ICP, and consent. CSP/CSP-HI/CSP-TPP authorizations require individualized service plans and documentation of housing status when applicable.

Include LABA vs technician hour breakdown, supervision, and parent training in ABA initial authorization
Include assessment, CPT notes, ICP, and consent for ICC authorizations
CSP-HI: include housing status, evidence of PSH opportunity, and timeline for move-in (billing may begin up to 120 days before move-in)

Documentation Required

Individualized service plans, evidence of coordination, and CSP intent/non-duplication

Individualized service plans, evidence of coordination, and documentation expectations for CSP — CSP programs are intended to provide non-clinical outreach/support services that complement clinical treatment and avoid duplication. Providers must document individualized CSP service plans, coordination with clinical providers, discharge planning, and measurable progress toward CSP goals. Enrollment may be excluded when the member is already receiving similar supportive services or when consent is not provided.

CSPs are not clinical treatment — document supportive activities that enable engagement in clinical care
Document individualized CSP service plans, coordination with clinical providers, and active discharge planning
Exclude enrollment when member receives duplicative supportive services or lacks consent

Documentation Required

Consultation documentation requirements for C-L psychiatry

Consultation documentation — Psychiatric consultation on inpatient medical units or EDs must document reason for consult, safety/stability assessment, mental status exam, relevant medical/medication history, and the treatment plan initiated. Consults should be limited to clinically appropriate cases; documentation that member can be safely managed without psychiatric consultation may be used as the basis for exclusion.

Document consult reason, exam, history, and plan in C-L psychiatry requests
Avoid consults when member can be safely managed without psychiatry — document rationale

Documentation Required

CSP-JI continued stay documentation expectations

CSP-JI continued stay documentation expectations — Continued stay requires evidence of active participation in the CSP-JI service plan, regular communication with staff, documented coordination with other providers, objective evidence of progress toward service plan goals, and documentation of adjustments when progress is insufficient. Lack of engagement or failure to demonstrate progress may trigger discharge or denial of continued services.

Document member participation, communication, coordination, and objective progress
Document adjustments to service plan when progress is insufficient

Billing Rule

CSP-HI documentation (housing imminence and pre-tenancy interventions); billing window

CSP-HI documentation and billing window — CSP-HI requires documentation of chronic homelessness or frequent acute service use, identification of a PSH opportunity with move-in within 120 days, and housing-related service plans (pre-tenancy, transition, tenancy sustaining). Providers may begin billing CSP-HI up to 120 days prior to move-in; once housed, continuous billing is permitted until Plan determines services are no longer medically necessary. CSP-HI cannot cover housing goods or move-in costs.

CSP-HI billing may begin up to 120 days before member moves into identified housing
Document PSH opportunity, time-to-move-in, and pre-tenancy/transition plans
CSP-HI does not pay for housing goods, deposits, or rent

Prior Authorization

Medical necessity for CSP services must be verified; enrollment exclusions for duplicative services or lack of consent

Medical necessity for CSP services must be verified — Providers must confirm that members meet general CSP medical necessity criteria (diagnosis or member attestation), document barriers to accessing outpatient/essential services or high utilization history, and ensure CSP is not duplicative of existing supports. For certain ACO/ACPP members (dates of service on/after 2025-01-01), Health Needs Based Criteria may be accepted to verify medical necessity. Enrollment is excluded when similar supportive services are already provided or consent is not given.

Verify medical necessity by diagnosis or member attestation; ACO/ACPP members may meet HNBC criteria (post-2025)
Document barriers to accessing services or high acute service utilization as justification
Exclude enrollment if duplicative services exist or consent is not provided

Step Therapy

Step-up requirement for IHBS; Step from less-intensive interventions before IHBS authorization; ABA justification

Step-up and sequencing requirements — IHBS/IHBS step-up: IHBS requires prior attempts at less-intensive interventions to have failed before authorization; IHBS admission criteria explicitly require less-intensive behavioral interventions to have been unsuccessful. FIT and other intensive community services require prior triage attempts and evidence that outpatient or less-intensive services alone are insufficient. ABA requests must document that no more-conservative or less-costly alternatives are available or suitable and providers must explicitly demonstrate attempts at less-intensive services when applicable.

IHBS requires documentation that less-intensive behavioral interventions were tried and unsuccessful
FIT requires prior triage and evidence that less-intensive services are insufficient
ABA requests must show that no more conservative/less costly alternatives are available or suitable

Prior Authorization

Triage prerequisite — prior triage attempts required

Triage prerequisite — For crisis and diversionary services (e.g., YMCI, FIT admission), prior triage attempts (phone triage or stabilization efforts by existing teams) are required and must be documented. Lack of triage or inadequate triage documentation may result in exclusion or denial.

Document prior triage attempts and stabilization efforts when requesting YMCI or FIT
Absence of documented triage may lead to denial

Prior Authorization

ABA requests must show there is no more conservative or less costly alternative

ABA requests must show there is no more conservative or less costly alternative — In accordance with regulatory guidance (130 CMR 450.204), ABA initial treatment authorizations must include evidence that no other available medical or behavioral health service or site of service is more conservative or less costly while being comparable in effect. Providers must document attempts or unsuitability of alternatives (e.g., IEP supports, early intervention, S/L therapy, OT/PT, CBHI).

Document why alternatives (IEP, early intervention, speech/OT/PT, CBHI) are unsuitable or insufficient
Include clear clinical justification when requesting higher intensity ABA hours

Documentation Required

Providers must show that less-intensive/less-costly alternatives were attempted

Providers must show that less-intensive services were attempted and documented before requesting more-intensive interventions — Authorization requests should include evidence of prior service attempts, provider outreach, and any mitigation efforts for access barriers. Review of continued necessity should consider progress data and documented efforts to address barriers before escalating care.

Include documentation of prior less-intensive interventions and outcomes
Document mitigation efforts for barriers to treatment adherence before requesting increased intensity

Note

Community Support Programs are intended to complement — not duplicate — outpatient clinical services

Community Support Programs are intended to provide non-clinical outreach and support to enable access and engagement in clinical treatment, and not to duplicate outpatient clinical services. CSPs assist members with daily living skills, service coordination, linkage to care, and removal of barriers to treatment. Documentation must demonstrate complementarity to clinical treatment and not duplicate existing services.

CSPs provide outreach/support, not clinical treatment — document complementary role
Avoid duplication of clinical outpatient services; document distinct supportive activities

Denial Risk

If member is receiving similar supportive services, CSP enrollment may be excluded

If a member is already receiving similar supportive services, CSP enrollment may be excluded — verify current services and document why additional CSP is clinically indicated. CSP-TPP and CSP-HI have specific exclusion criteria related to eviction/trial status and duplicative services — ensure eligibility and consent before billing or enrollment.

Exclude CSP enrollment when similar supportive services are already present
CSP-TPP exclusion: members with eviction cases already tried in District or Boston Municipal Court are not eligible; Housing Court cases may be conditionally eligible
Ensure consent prior to enrollment in CSP programs

Definitions and Program Descriptions

inv-165: Acute, High-Intensity Inpatient Services definition

DefinitionA psychiatric inpatient service providing single rooms, limited census, enhanced staffing, and increased observation/intervention for atypical aggressive, assaultive, or dangerous behavior

PurposeAcute stabilization and transition to general inpatient or less-intensive care

Distinguishing featuresHigher security/containment and specialized staff beyond general inpatient capability

inv-166: Community-Based Acute Treatment (CBAT) definition

DefinitionA 24/7 unlocked acute treatment setting for children/adolescents providing intensive therapeutic services within a structured multidisciplinary treatment plan

ServicesDaily medication monitoring, psychiatric assessment, therapy, case management, family involvement and discharge planning

SettingStaff-secure (unlocked) with high supervision and structure

inv-167: Co-Occurring Enhanced RRS definition

DefinitionAn ASAM 3.1 Residential Recovery Services level for members with co-occurring SUD and moderate-severe mental health conditions requiring small milieu, high staff-to-member ratios, and possible 24-hour supervision

Key needsImmediate medication evaluation/reconciliation and structured support to access prescribers

Utilization indicatorRecent inpatient psych hospitalization or ≥2 ED/MCI evaluations within 3 months or unsuccessful engagement in community services

inv-168: Transitional Care Unit (TCU) definition

DefinitionA short-term program for youth in DCF custody who no longer meet inpatient criteria but need community exposure/therapeutic milieu to support transition

Expected timeframeFacilitates transition in 30 days or less

PopulationYouth under DCF custody expected to return to home, foster care, group home, or residential placement

inv-169: Intensive Care Coordination (ICC) definition

DefinitionA wraparound, family-driven care coordination service that convenes a Care Planning Team to develop and implement an Individual Care Plan (ICP) and risk/safety plan

Core functionsCare coordination, convening CPT, ICP development, monitoring progress, and linking to services

PopulationMassHealth youth with Serious Emotional Disturbance (SED) under age 21

inv-170: In-Home Therapy (IHT) definition

DefinitionTeam-delivered, in-home psychotherapeutic services focused on family dynamics, crisis response, skills-building, and strengthening caregiver supports

FormatDelivered by licensed clinicians with paraprofessionals; flexible session length and scheduling; 24/7 urgent response capability

SettingHome and natural community settings (including schools, respite, community locations)

inv-171: In-Home Behavioral Services (IHBS) definition

DefinitionIn-home behavior management therapy and monitoring including Functional Behavioral Assessment, behavior plan development, implementation, caregiver training, and progress monitoring

ComponentsBehavior Management Therapy (assessment, plan, supervision) and Behavior Management Monitoring (implementation, caregiver reinforcement, reporting)

PopulationMassHealth Standard/Commonhealth members under 21 (with commercial variant under 19) when less-intensive interventions failed

inv-172: Family Support & Training (FS&T) / Family Partner definition

DefinitionA family-centered role providing education, coaching, system navigation assistance, frequent contact with caregivers, and attendance at Care Planning Team meetings

Provider typeStrength-based paraprofessional under licensed clinician supervision

GoalImprove caregiver capacity to support youth functioning and achieve treatment plan/ICP goals

inv-173: Behavior Management Therapy definition

DefinitionAssessment, development of a specific behavior plan, supervision/coordination of interventions, and training of other interveners to address targeted behavioral objectives

RoleDelivered as Behavior Management Therapy within IHBS to treat challenging behavior interfering with functioning

RelationInforms Behavior Management Monitoring and Behavior Intervention Plans (BIP)

inv-174: Behavior Management Monitoring definition

DefinitionImplementation and monitoring of the behavior plan, reinforcement of caregiver implementation, and reporting progress to the behavior management therapist; includes phone contact/consultation

PurposeSustain behavior plan fidelity across home/school settings and document progress

SettingDelivered in home/community as part of IHBS team services

inv-175: Therapeutic Mentoring (TM) definition

DefinitionStructured one-to-one support to coach youth in daily living, social, communication, and functional skills pursuant to a behavioral health treatment plan or ICP

SettingProvided in home, school, community settings for youth under 21 (MassHealth) or under 19 (commercial) as applicable

ReportingProgress must be documented regularly and tied to treatment goals

inv-176: Family Partner (FP) definition

DefinitionParaprofessional, strength-based, culturally and linguistically appropriate provider who works one-on-one with parent/caregiver to improve parenting capacity

SupervisionDelivered by qualified paraprofessionals under licensed clinician supervision

Target populationCommercial members under age 19 (Family Partner) or MassHealth contexts when applicable

inv-177: Family-based Intensive Treatment (FIT) definition

DefinitionA multidisciplinary team (clinician, paraprofessional, Family Partner) delivering intensive family therapy, care coordination, and 24/7 crisis response to maintain community placement for youth with SED

Goal/timeframeAim to transition youth to less-intensive services within approximately 4–6 months

FeaturesTeam-delivered, home/community-based, flexible scheduling, urgent response capability

inv-178: Adult Mobile Crisis Intervention (AMCI) definition

AMCI Definition24/7 community-based crisis assessment, intervention, stabilization and follow-up for adults, provided mobile or via telehealth; up to three days for AMCI

YMCI Definition24/7 community-based crisis assessment, intervention, stabilization and follow-up for youth under 21, provided mobile or via telehealth; up to seven days for YMCI

ServicesOn-site face-to-face therapeutic response, psychiatric consultation, urgent psychopharmacology, referrals and linkages

inv-179: Youth Mobile Crisis Intervention (YMCI) definition

YMCI DefinitionCommunity-based behavioral health crisis assessment, intervention, stabilization and follow-up for youth under 21, available 24/7 and up to seven days

ACCS/YCCS DefinitionFacility- or community-based program providing continuous 24-hour observation and supervision as an alternative to hospitalization for short-term stabilization

CPS DefinitionCertified Peer Specialists are individuals in sustained recovery certified to support peers via non-clinical mentoring, advocacy, and linkage to recovery resources

inv-180: Community Crisis Stabilization (ACCS/YCCS) definition

DefinitionFacility- or community-based program providing continuous 24-hour observation and supervision in a staff-secure setting as an alternative to hospitalization for short-term stabilization

ServicesCrisis stabilization, bio-psychosocial assessment, medication management, care coordination, mobilization of supports

ObjectiveStabilize and restore functioning to allow return to less-restrictive care

inv-181: Certified Peer Specialist (CPS) definition

DefinitionIndividuals in sustained recovery who are certified to support peers via non-clinical mentoring, advocacy, and linkage to recovery resources

RoleShare lived experience, mentor, link to recovery community, and assist with navigation of supports

SettingsDelivered across CBHC components including crisis stabilization and mobile crisis

inv-182: Diagnostic Evaluation definition

DefinitionAssessment of level of functioning across physical, psychological, social, educational, and environmental domains to inform diagnosis and treatment planning

UseRequired for many admission decisions and initial authorization documentation

ComponentsHistory, mental status, functional assessment, and relevant standardized tools

inv-183: Medication Visit definition

DefinitionIndividual visit for psychopharmacological evaluation, prescription, review, and/or monitoring by a psychiatrist or RN clinical specialist

PurposeMedication management, efficacy and side-effect monitoring

SettingOutpatient, inpatient bridge visits, or consultation-liaison contexts as appropriate

inv-184: DBT definition

DefinitionDialectical Behavior Therapy (DBT): manual-directed outpatient treatment including skills group, individual therapy, team consultation, and 24-hour telephone coaching

Typical componentsWeekly 2-hour skills group, individual therapy, telephone coaching, team consultation; 6–12 month treatment agreement

IndicationBPD and chronic parasuicidal behaviors or other diagnoses with evidence of DBT efficacy

inv-185: Applied Behavior Analysis (ABA) definition

DefinitionApplied Behavior Analysis (ABA): scientific discipline using direct observation, measurement, and functional analysis to design interventions producing meaningful behavior change

Service componentsDirect/indirect assessment, skill-based tools, FBA/BIP when reducing behavior, parent training, LABA vs technician staffing

SettingsHome/community preferred; center-based only when clinically justified with generalization plan

inv-186: Early Intensive Behavioral Intervention (EIBI) definition

DefinitionEarly Intensive Behavioral Intervention (EIBI): intensive ABA program for children 0–3 delivered in natural settings with assessments, parent training, and coordination with early intervention providers

SettingHome/community (not center-based); aligns with IFSP and EIP referrals

Admission noteReferral from EIP and confirmed ASD diagnosis required

inv-187: Recovery Coach (RC) definition

DefinitionRecovery Coach (RC): an individual with lived experience who provides non-clinical peer support, develops a Wellness Plan, and links members to recovery resources

Admission/engagementAvailable via referral; continued engagement requires at least one contact every 21 days

RolesMotivation, harm reduction education, community linkage, support for MAT engagement as needed

inv-188: Community Support Program (CSP) definition

DefinitionCommunity Support Program (CSP): community-based, mobile, paraprofessional staff-supported programs providing outreach and supportive services to enable access and utilization of clinical behavioral health services and prevent hospitalization

PurposeSupport members with DSM diagnoses at risk for hospitalization to implement clinical treatment plans and maintain community tenure

VariantsCSP-HI (homeless individuals) and CSP-TPP (tenancy preservation program) with program-specific housing criteria

inv-189: Consultation-Liaison (C-L) Psychiatry definition

DefinitionConsultation-Liaison (C-L) Psychiatry: psychiatric consultation for medically/surgically ill inpatients or ED patients to ensure safety, conduct assessment, and initiate treatment including medications when appropriate

AimsSafety/stability in medical setting, history/medical data collection, mental status exam, and active treatment planning

SettingInpatient medical units and EDs upon request of medical team

inv-190: Justice Involvement definition

DefinitionJustice Involvement: former inmate/detainee released within past year or individual under supervision of Massachusetts Probation/Parole

UseRelevant to CSP-JI admission criteria and program targeting

DocumentationJustice involvement status determined by probation/parole documentation or release records

inv-191: Homelessness / PSH / HNBC definitions

Definitions groupedChronic Homelessness, Homelessness, Permanent Supportive Housing (PSH) and Health Needs Based Criteria (HNBC)

Chronic HomelessnessHUD definition: disabled individual continuously homeless ≥12 months or 4+ episodes over 3 years totaling ≥12 months

HNBC elementsBehavioral health need, complex physical health need, ADL/IADL assistance, repeated ED use (2+ in 6 months or 4+ in 12 months), pregnancy-related criteria

inv-192: Homelessness definition

HomelessnessLacking a fixed, regular, adequate nighttime residence including emergency shelters, places not meant for habitation, or exiting institutions when previously homeless

ExamplesSleeping in car, park, abandoned building, emergency shelter, transitional housing; includes recent exit from institution if previously homeless

RelevanceUsed to determine CSP-HI and tenancy preservation eligibility

inv-193: At Risk of Homelessness definition

At risk of homelessnessMember lacking sufficient resources or support networks immediately available to prevent moving to an emergency shelter or place not meant for habitation

ImplicationUsed for CSP-TPP and other tenancy-preservation eligibility assessments

ExamplesLoss of income, eviction notices, imminent housing instability without supports

inv-194: Eviction / Notice to Quit definition

Eviction / Notice to QuitEviction: process to obtain court order to remove tenant; Notice to Quit: landlord's written notice terminating tenancy

UseRelevant to CSP-TPP admission where facing eviction at start of services is required (with court trial exceptions)

DocumentationCourt filings, notices, or landlord communications typically required to verify status

inv-195: Health Needs Based Criteria (HNBC) definition

HNBC definitionQualifying criteria including behavioral health need, complex physical health need, need for ADL/IADL assistance, repeated ED use, and pregnancy/postpartum factors

Repeated ED use thresholdTwo or more visits within 6 months or four or more within 12 months

UseSome ACO plans may use HNBC to meet medical necessity for CSP services on/after 1/1/2025

Service Durations, Frequencies and Billing Windows

inv-234: Transitional Care Unit expected maximum transition timeframe (days)

TCU maximum transition timeframe (days)30

ContextExpected period to transition youth to next placement setting

ApplicabilityYouth in DCF custody transitioning from inpatient/ICBAT/CBAT/YCCS/CBAT ID/ASD

inv-235: In-Home Therapy (IHT) visit/format note

IHT session formatFlexible session length and setting; not time-limited per session

Team compositionDelivered by a qualified clinician with possible paraprofessional team members

Response capabilityIncludes 24/7 urgent response capability

inv-236: YMCI crisis intervention maximum duration

YMCI maximum durationUp to seven days per crisis episode

AvailabilityYMCI services available 24/7/365

Services includedOn-site face-to-face response, psychiatric consultation, urgent psychopharmacology, referrals/links

inv-237: ABA initial direct and indirect assessment (up to 12 hours)

ABA initial assessment limitUp to 12 hours of direct and indirect assessment

Completion timeframeMust be completed within 45 calendar days of assessment authorization

PurposeInform initial treatment plan and authorization

inv-238: Recovery Coach engagement minimum contact frequency

Recovery Coach engagement minimumAt least one contact every 21 days

Continued stay requirementDocumented active involvement and progress on Wellness Plan; coordination with providers

Discharge triggerFewer than one contact every 21 days may support discharge/denial

inv-239: CSP-HI billing window (120 days pre-housing)

CSP-HI billing windowProviders may bill up to 120 days before member moves into housing (pre-tenancy)

ConditionRequires identified PSH opportunity and move within 120 days or homeless medical respite with PSH plan

Post-move-in billingBilling may continue after move-in until Plan determines service no longer medically necessary

Background and Scope

This policy defines Carelon Behavioral Health’s medical necessity framework for inpatient, diversionary, and intensive community behavioral‑health services in Massachusetts. It sets the purpose of ensuring members receive the least‑restrictive, clinically appropriate level of care and to guide providers on admission, continued stay, discharge, and exclusion rules across multiple service lines.

Services covered range from high‑intensity inpatient care to short‑term diversionary alternatives (CBAT/ICBAT), specialized residential recovery services (Co‑Occurring Enhanced RRS per ASAM Level 3.1), Transitional Care Units (TCU), and a broad suite of in‑home and community supports (IHT, IHBS, FS&T, ICC, TM, FIT, CPS, RSN, Recovery Coach, CSP, PACT, and consultation‑liaison psychiatry).

Key policy objectives for providers: apply the listed medical‑necessity criteria when seeking authorization; document required assessments (DSM‑5‑TR/ICD diagnosis, MA CANS, FBA when indicated, ASAM six‑dimension for SUD), confirm voluntary consent where required, demonstrate less‑intensive options were considered or attempted when required, and recognize specific exclusions (for example concurrent IHBS+ABA, lack of placement readiness for ICC/TCU, or acute medical needs requiring a medical setting).

Behavioral health medical necessity criteria (Massachusetts)

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Coverage and Medical Necessity Criteria

Referenced Codes and Coding Guidance

Actions, Prior Authorization, Documentation and Billing

Definitions and Program Descriptions

Level-of-Care Specific Criteria

Treatment Modalities and Service Components

Applied Behavior Analysis (ABA) - Criteria and Visit Limits

Service Durations, Frequencies and Billing Windows

Background and Scope

Revision History and Policy Changes