Social Needs Companion Benefit
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Defines medical necessity criteria and prior authorization requirements for Longevity Health Plan of Colorado's supplemental social needs companion benefit for members with acute behavioral or mental health needs who may benefit from short-term companionship services.
No material clinical or coverage changes in this revision.
Medical Necessity & Exclusions
Medical Necessity Criteria
Covered when ALL of the following are met
Benefit is supplemental; plan limits apply
Explicit exclusion
Full list provided in policy
Specific behaviors enumerated in policy
Either measure satisfies this node
Care plan required
The social needs companion benefit does not apply if there is any indication the member is an active danger to themselves. In such cases, the policy requires a higher level of care and the companion benefit is not an appropriate intervention.
Requests for the social needs companion benefit for members who are actively dangerous to themselves will be considered not appropriate for this supplemental benefit because the policy specifies that a higher level of care is warranted in these situations.
Assessment Scores & Definitions
Authorization & Documentation Requirements
Prior authorization required after plan‑specified hours
Prior authorization is required once the member has exceeded the plan‑specified number of social needs companion service hours. The authorization request must include the required documentation (diagnosis, recent observed behaviors, objective score, and care plan) for clinical review.
- Prior authorization only required after member has exceeded a certain number of companion service hours (see Evidence of Coverage).
- Authorization requests must include required clinical documentation of diagnosis, recent observed behaviors, objective score, and care plan.
Confirm benefit hours and submit to UM for review
Verify member benefit hours remaining before submitting a request; the provider is responsible for determining available hours and for submitting the authorization to utilization management for clinical review.
- Providers must check member’s Evidence of Coverage for plan limits and remaining companion service hours.
- Utilization management will apply clinical criteria during authorization review; prior authorization is not a guarantee of payment.
Required documentation to include with authorization
Include evidence of a qualifying diagnosis, documented observed behavior within the 72 hours prior to submission, one objective score (BARS ≥5 or PHQ‑9 >15), and a provider care plan with the authorization request.
- Evidence of a qualifying diagnosis from the policy’s list (e.g., dementia, diabetes, neurologic disorders, chronic SUDs, etc.).
- Documented observed behavior within 72 hours (examples: yelling/screaming, physical or verbal aggression, anger, anxiety, frequent crying, or other behavior linked to the diagnosis).
- One objective measure: BARS score 5 or higher OR PHQ‑9 higher than 15.
- Provider documentation of a care plan for the social needs companion.
Prior authorization reminder after hours exceeded
Reminder: submit a prior authorization request when the member has used more than the plan‑specified companion service hours; verify remaining hours beforehand and attach required clinical documentation for UM review.
- Prior authorization applies only after the member has exceeded the number of hours in the Evidence of Coverage.
- Providers must confirm remaining benefit hours before requesting authorization.
- Attach diagnosis, recent observed behaviors, objective score, and care plan to the request.
Denial risk: active danger to self
Do not request the companion benefit for members who are an active danger to themselves; such requests will be denied because a higher level of care is warranted.
- Any indication the member is an active danger to self excludes them from the social needs companion benefit.
Appropriate Setting & Service Level
Outpatient / supplemental companion service criteria
Used for authorizing companion services
Policy implies short-term companion support; specific continued-stay intervals not specified in document
Permitted Companion Service Types
Companion services
Described in Purpose
Benefit Hours & Limits
Benefit Purpose
The social needs companion benefit provides short-term companionship support delivered by a credentialed companion to engage members in social, physical, or mental activities. It is a supplemental outpatient service intended to help members address acute behavioral or mental health needs and to assist those who may need accompaniment to maintain function or reduce distress. Use of the benefit is governed by the member's Evidence of Coverage and plan-specified limits; prior authorization is required when benefit hours have been exceeded.
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