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

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

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 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

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

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

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

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

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

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

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

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

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 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

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

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 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

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

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

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

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)

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

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)

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

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

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

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

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-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

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

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

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

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

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

Include LABA/technician hours, supervision, and parent training in ABA initial requests

For ABA initial assessment and treatment authorization, include detailed provider recommendations (LABA vs technician hours), supervision plan, parent training, and justification that no more conservative/less costly option is suitable.

• Provide summary of direct/indirect hours, supervision frequency, and parent training schedule.
• Include evidence per 130 CMR 450.204 that alternatives were considered and found unsuitable.