Voluntary Care Management (VCM) - Coverage Criteria
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Defines eligibility and program purpose for families with children under 18 who have a primary mental health or substance use disorder and who seek assistance to access appropriate behavioral health services and address barriers to care.
No material clinical or coverage changes in this revision.
Voluntary Care Management (VCM) — Eligibility & Exclusions
Families are ineligible for Voluntary Care Management (VCM) when any of the following exclusionary conditions are present: an active Department of Children and Families (DCF) investigation or ongoing DCF services involvement; the child or youth is the subject of a pending delinquency petition, has been adjudicated delinquent and is awaiting disposition, is on probation, committed, on parole, or is currently involved with the adult criminal justice system due to arrest, conviction, probation, or parole; the child has a Department of Developmental Services (DDS) case manager with a current Individual Plan and services already implemented as defined in that plan; the child or youth was placed out of home prior to the request for VCM; the primary reason for referral is not related to a behavioral health diagnosis; or the family refuses to engage in the program and/or participate in the child’s treatment.
Provider Responsibilities, Documentation & Enrollment
Prior Authorization
No prior authorization codes are specified for Voluntary Care Management (VCM). Enrollment decisions are made by screening referrals against program exclusions; do not assume an authorization pathway exists.
Operational Action
If a referral meets any exclusion criteria, the referral must be declined and the provider notified. Providers should document outreach and any attempted engagement activities in the member record when disposition is a decline due to ineligibility.
Documentation Required
Providers must document in the referral and clinical record that none of the listed ineligibility conditions apply to the family. At minimum include: verification of Department of Children and Families (DCF) involvement status; juvenile/criminal justice involvement for the child/youth; Department of Developmental Services (DDS) case management or active Individualized plan status; timing of any out-of-home placement relative to the VCM request; the primary reason for referral (must be behavioral health–related); and evidence of family willingness to engage.
Ineligibility Triggers - Denial Risk
The following conditions will trigger denial of enrollment into VCM and must be confirmed by the provider before submission: active DCF investigation or ongoing DCF services; pending delinquency petition, adjudication-related detention/probation/parole, or current adult criminal justice involvement; active DDS case manager with an implemented individual plan; out-of-home placement made prior to the VCM request; referrals whose primary reason is not a behavioral health diagnosis; or family refusal to engage.
Key Definitions
Background & Scope
Voluntary Care Management (VCM) serves families with children under age 18 when the child has a primary mental health or substance use disorder and the family seeks assistance to access appropriate behavioral health services. The program’s goal is to facilitate and develop a plan of care that identifies the most appropriate clinical level of service and addresses systemic or financial barriers that impede access to needed behavioral health care.
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