CurrentBeacon-Health-OptionsPolicy N/A

Psychiatric Disability Determination Criteria for Dependents

Defines medical necessity criteria and admission/continued-stay rules for determining psychiatric disability in dependents under the New York State Empire Plan; applies to providers evaluating dependent eligibility and level-of-care for Beacon-Health-Options/Carelon Behavioral Health.

Policy Summary

PayerBeacon-Health-Options

PolicyPsychiatric Disability Determination Criteria for Dependents

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of dependent eligibility, DSM/ICD diagnosis, objective evidence and impairment duration of at least six months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsminimum continuous duration required to qualify as a disability

All criteria must be metAdmission/continued-stay requirement

Dependentspopulation eligible under this policy

Requiredobjective evidence required

Coverage and Level-of-Care Admission Rules

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Admission — Admission Criteria

Admission Criteria — All of the following must be met:

Admission criteria: 1) Eligible as a dependent under the policyholder's benefit plan. 2) Symptomatology consistent with an ICD-10 or current DSM diagnosis resulting in a documented mental impairment. 3) The impairment has lasted or is expected to last at least six months.duration >= 6 months

Measurable assessment of functioning and objective documentation required from licensed professionals; prior authorization should include these elements.

Functional severity (one of the following must be met)

Option A: Impairment severe enough to cause inability to engage in any substantial gainful activity despite medical and therapeutic intervention, demonstrated by consistent disruptions in role functioning (e.g., school, work, parenting/household responsibility, self-care, basic living skills) with marginal or ineffective contribution relative to expected level.
Option B: Impairment causes serious to severe functional limitations, demonstrated by at least moderate functional deficits requiring constant supervision, support and special programming in most areas (academics, peer relations, etc.).

Operational note: Admission requires objective documentation of signs, symptoms, and measurable functional impairment; documentation should include licensed clinician assessments and may include collateral information from schools, employers, social services.

Continued Stay — Continued Stay Criteria

Continued Stay Criteria — All of the following must be met:

Continued stay: 1) Continues to meet the admission criteria described above. 2) Participating in a regular treatment protocol as recommended by the attending physician/primary clinician/treatment team. 3) When medically necessary, appropriate psychopharmacological intervention has been evaluated and prescribed when indicated, with regular psychopharmacological reviews. 4) Treatment includes ongoing, measurable assessment of the individual's ability to function.

Document ongoing treatment engagement, treatment planning, and response to interventions.

Substance use that by itself causes impaired functioning, and that is uncomplicated by a serious co‑morbid psychiatric condition, is excluded from authorization at this level of care. The policy explicitly lists this as an exclusionary condition and notes that such presentations are not sufficient for admission or continued stay under the dependent psychiatric disability criteria.

Other exclusionary conditions include refusal or non‑participation in treatment that might reasonably be expected to improve or stabilize the dysfunction, conditions determined to be medical disabilities, and onset of disability after the dependent’s 26th birthday.

Documentation, Prior Authorization, and Exclusions for Providers

Prior Authorization

Prior Authorization Required for Admission

Admission requires prior authorization documentation. All admission criteria must be met and clearly documented in the prior authorization request, including dependent eligibility under the policyholder's benefit plan, a DSM/ICD-consistent diagnosis, and demonstration that the impairment has lasted or is expected to last at least six months. Admissions that do not include the required documentation may be denied or deferred.

Must be eligible as a dependent under the policyholder's benefit plan.
Symptomatology consistent with ICD-10 or current DSM diagnosis with documented mental impairment.
Impairment lasted or expected to last >= 6 months and is severe enough to preclude substantial gainful activity despite intervention.

Documentation Required

Documentation Must Include Objective Medical/Psychological Evidence

Required supporting documentation must accompany assessments and prior authorization requests. Objective medical or psychological evidence is required — subjective reporting alone is insufficient.

Documentation of demonstrable and measurable signs, symptoms, laboratory and psychological test findings.
Examinations and evaluations by licensed physicians, licensed/certified psychologists, or other credentialed health care practitioners.
Collateral information from other sources (e.g., teachers, social workers, employers, public/private social welfare agencies) to show functional impact.
Records of treatment history and responses to prior interventions, including medication trials and psychotherapy, when applicable.

Documentation Required

Document Diagnosis and Duration

Diagnosis and duration must be documented and consistent with presenting symptoms. The record must show an ICD-10 or current DSM diagnosis and that the impairment has lasted or is expected to last at least six continuous months.

Clear ICD-10 or current DSM diagnosis that matches symptomatology.
Evidence that impairment causes significant functional disruption (e.g., school, work, parenting, self-care, basic living skills).
Statement and supporting evidence that impairment duration is >= 6 months or expected to meet that threshold.

Denial Risk

Uncomplicated Substance Use Exclusion

Exclusion: uncomplicated substance use is not sufficient for admission to this level of care. If substance use alone causes impairment without a serious comorbid psychiatric condition, the episode is excluded from this level of care and should be managed under appropriate substance use treatment benefit pathways.

Substance use alone resulting in impaired functioning, uncomplicated by serious comorbid psychiatric conditions, is excluded from this level of care.
When substance use co-occurs with serious psychiatric comorbidity, document the psychiatric condition and its contribution to functional impairment.

Denial Risk

Non‑Participation May Lead to Exclusion

Non-participation in recommended treatment that could reasonably be expected to improve or stabilize the dysfunction is a basis for exclusion or denial. Treatment participation (or documented barriers to participation) should be clearly recorded.

If the individual is not participating in treatment likely to improve stabilization, this may be sufficient to deny authorization.
Document attempts to engage the individual, reasons for non-participation, and any efforts to address barriers to treatment (e.g., transportation, consent, comorbid medical issues).

Definitions and Functional Criteria

inv-12: Disability — Disability: inability to engage in any substantial gainful activity due to medical or psychological impairment(s) lasting or expected to ...

DefinitionDisability: inability to engage in any substantial gainful activity due to medical or psychological impairment(s) lasting or expected to last continuously for not less than six months.

Evidence standardMental impairment must be established by objective medical/psychological evidence (demonstrable and measurable signs, symptoms, laboratory and psychological test findings).

Sources of evidenceExaminations by licensed physicians, licensed/certified psychologists, or other qualified practitioners; collateral information from social welfare agencies, teachers, social workers, and employers may supplement.

inv-13: Serious to Severe functional limitations — "Serious to Severe functional limitations" are demonstrated by at least moderate functional deficits requiring constant supervision, supp...

Definition"Serious to Severe functional limitations" are demonstrated by at least moderate functional deficits requiring constant supervision, support and special programming in most areas (e.g., academics, peer relations).

Functional impact examplesMay include need for constant supervision, specialized programming, and marked deficits across school, peer, and daily living domains.

Role in admission criteriaPresence of these limitations satisfies one pathway for admission when impairment causes inability to function despite intervention or meets the serious-to-severe standard.

Background and Policy Scope

Disability for the purposes of this policy is an inability to engage in any substantial gainful activity due to a medical or psychological impairment that has lasted or is expected to last continuously for at least six months. Documentation must support a DSM/ICD diagnosis and demonstrate objective evidence of the mental impairment and its functional impact.

The policy requires that the impairment either (a) cause inability to engage in substantial gainful activity despite intervention (demonstrated by consistent disruptions in role functioning such as school, work, parenting, self‑care or basic living skills) or (b) produce serious to severe functional limitations — defined as at least moderate functional deficits requiring constant supervision, support and specialized programming in most areas.

OpenPayer

Psychiatric Disability Determination Criteria for Dependents

Coverage and Level-of-Care Admission Rules

Scope: Policy Governance for Dependent Psychiatric Care

Required and Considered Treatments

Key Coding & Duration Values

Documentation, Prior Authorization, and Exclusions for Providers

Definitions and Functional Criteria

Background and Policy Scope