CurrentOptumPolicy BH803!L052025

Illinois Commercial Supplemental Clinical Criteria: Medical Necessity for Serious Mental Illness Under Age 26

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State-specific supplemental clinical criteria for Illinois governing medical necessity determinations for Assertive Community Treatment (ACT), Community Support Team (CST) treatment, and Coordinated Specialty Care (CSC) for first-episode psychosis for members under age 26 enrolled in Optum-managed behavioral health plans.

Policy Summary

PayerOptum

PolicyMedical Necessity for Serious Mental Illness Under Age 26

Policy CodePolicy BH803!L052025

Change TypeNo material change

Effective DateMay 1, 2025

Next Review Date

Key ActionVerify member eligibility, member-specific benefits, and applicable state regulatory requirements before applying these clinical criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentOptumPolicy BH803!L052025

Illinois Commercial Supplemental Clinical Criteria: Medical Necessity for Serious Mental Illness Under Age 26

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Policy Summary

PayerOptum

PolicyMedical Necessity for Serious Mental Illness Under Age 26

Policy CodePolicy BH803!L052025

Change TypeNo material change

Effective DateMay 1, 2025

Next Review Date

Key ActionVerify member eligibility, member-specific benefits, and applicable state regulatory requirements before applying these clinical criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3service bundles described

14–25CSC age range

18 monthsmax time since first psychosis

thresholdsLOCUS/CALOUS thresholds

5revision entries through

Coverage and Medical Necessity Criteria

Assertive Community Treatment (ACT) — Initiation, Continued Stay, Discharge

ACT covered when ALL of the following are met

Service initiation - ACT: Member has a DSM psychiatric diagnosis causing severe and persistent symptoms; minimum LOCUS or CALOCUS composite score of 17; member (and parent/guardian when appropriate) willing to accept ACT services; less intensive mental health treatment has not improved symptoms or is inappropriate and the individual exhibits three or more specified risk/complexity indicators3 of listed indicators

Continuing stay - ACT: Severity of illness and resulting impairment continue to meet initiation criteria; without these services the individual would not be able to sustain treatment gains and would have increased symptoms and decreased functioning; individualized treatment planning with realistic and specific goals; mode, intensity and frequency of treatment are appropriate; active treatment with continued progress or documented plan adjustments; member (and parent/guardian when appropriate) actively participating and willing to continue

Discharge - ACT: Discharge when any: treatment plan and discharge goals substantially met; consent withdrawn; individual no longer meets initiation criteria or meets criteria for a different level of care; or individual (and parent/guardian when appropriate) is not engaged or utilizing the service to such a degree that treatment at this level becomes ineffective or unsafe despite motivational techniques and multiple documented attempts

Community Support Team (CST) — Initiation, Continued Stay, Discharge

CST covered when ALL of the following are met

Service initiation - CST: Member has a DSM psychiatric diagnosis with LOCUS or CALOCUS composite score 14-20 causing moderate to severe symptoms; member (and parent/guardian when appropriate) willing to accept CST services; outpatient mental health treatment has not resulted in improved symptoms or is inappropriate and the individual exhibits three or more specified indicators3 of listed indicators

Continuing stay - CST: Severity of illness and resulting impairment continue to meet initiation criteria; without these services the individual would not be able to sustain treatment gains and would have increased symptoms and decreased functioning; individualized treatment planning with realistic and specific goals; mode, intensity and frequency of treatment are appropriate; active treatment with continued progress or documented plan adjustments; member (and parent/guardian when appropriate) actively participating and willing to continue

Discharge - CST: Discharge when any: treatment plan and discharge goals substantially met; consent withdrawn; individual no longer meets initiation criteria or meets criteria for a different level of care; individual not engaged or utilizing the service despite motivational techniques and multiple documented attempts; or significant increase in symptoms with decreased functioning resulting in transition to ACT

Coordinated Specialty Care (CSC) for First Episode Psychosis — Initiation, Continued Stay, Discharge

CSC covered when ALL of the following are met

Service initiation - CSC: Individual aged 14-25; experienced first significant symptoms of psychosis or a psychotic episode within the last 18 months; member (and parent/guardian when appropriate) willing to accept CSC services

Continuing stay - CSC: Severity of illness and resulting impairment continue to require this level of service; without these services the individual would not be able to sustain treatment gains and would have increased symptoms and decreased functioning; individualized treatment planning with realistic and specific goals; mode, intensity and frequency of treatment are appropriate; active treatment with continued progress or documented plan adjustments; member (and parent/guardian when appropriate) actively participating and willing to continue

Discharge - CSC: Discharge when any: treatment plan and discharge goals substantially met; consent withdrawn; individual no longer meets initiation criteria or meets criteria for a different level of care; or individual (and parent/guardian when appropriate) is not engaged or utilizing the service to such a degree that treatment at this level becomes ineffective or unsafe despite motivational techniques and multiple documented attempts

The following situations are exclusions for Assertive Community Treatment (ACT) and make ACT inappropriate: when symptoms primarily originate from an intellectual disability, neurodevelopmental or neurocognitive disorder, substance-related or -induced disorder, or personality disorder; when there has been a rapid onset of psychosis due to sleep deprivation not associated with another psychotic disorder or condition; when the individual’s symptoms and functioning are sufficient to progress with less intensive mental health services; when the individual’s level of cognitive impairment, current mental status, or developmental level makes benefit from ACT unlikely; or when the individual requires a more intensive level of service.

The following situations are exclusions for Community Support Team (CST) treatment and make CST inappropriate: when symptoms primarily originate from an intellectual disability, neurodevelopmental or neurocognitive disorder, substance-related or -induced disorder, or personality disorder; when there has been a rapid onset of psychosis due to sleep deprivation not associated with another psychotic disorder or condition; when the individual’s daily living skills are sufficient to progress with outpatient mental health services; when the individual’s level of cognitive impairment, current mental status, or developmental level makes benefit from CST unlikely; or when the individual requires a more intensive level of service and cannot be safely or effectively treated with CST.

Coordinated Specialty Care (CSC) for first-episode psychosis is not appropriate in the following circumstances: if the individual experienced a first psychotic episode more than 18 months ago; if the symptoms to be addressed primarily originate from an intellectual disability, neurodevelopmental or neurocognitive disorder, substance-related or -induced disorder, personality disorder, or brain injury; or if there was a rapid onset of psychosis due to sleep deprivation that is not associated with another psychotic disorder or condition. Document the timing of the first psychotic episode and the diagnostic basis when submitting for CSC eligibility.

Specifically, CSC eligibility is excluded when the individual’s first psychotic episode occurred more than 18 months ago, or when the presenting symptoms have their primary origin in an intellectual disability, neurodevelopmental or neurocognitive disorder, substance-related or -induced disorder, personality disorder, or brain injury. These conditions should be considered exclusionary during medical necessity review and may result in denial if present.

Key Thresholds and Code-Related Values

ACT LOCUS/CALOUS composite score

MeasureLOCUS or CALOCUS composite score

Threshold>= 17 (minimum composite score required for ACT initiation)

ContextUsed as part of ACT admission criteria to document severity causing severe and persistent symptoms

CST LOCUS/CALOUS composite score

MeasureLOCUS or CALOCUS composite score

Range14–20 (composite score range for CST initiation)

ContextRequired in CST admission criteria to indicate moderate to severe psychiatric symptoms

Provider Requirements, Documentation, and Authorization Notes

Documentation Required

Pre-review checks

All reviewers must verify member eligibility, the member-specific benefit plan coverage, and any applicable federal or state regulatory requirements before using these Clinical Criteria. If the requested service is limited, excluded, or conflicts with the member's benefit language, the member's specific benefit supersedes these Clinical Criteria.

Confirm member eligibility and active enrollment
Verify the member-specific benefit plan for coverage, limits, and exclusions
Check for federal or state regulatory requirements that supersede plan benefits

Step Therapy

Prior less-intensive treatment requirement

For initiation of ACT, CST, or CSC services, documentation must show that less intensive outpatient mental health treatment has not resulted in improved symptoms or functioning, or is not appropriate at the current time.

Policy Background

These specialty team-based services — Assertive Community Treatment (ACT), Community Support Team (CST), and Coordinated Specialty Care (CSC) — are multidisciplinary bundles of services delivered by teams of mental health professionals. Their purpose is to mitigate severe or first-episode psychosis symptoms, support recovery, increase functioning, and decrease hospitalizations by delivering care both in-office and in the person’s natural environment, emphasizing engagement, wellness, self-management, resiliency, and use of natural supports.

Definitions and Exclusions

ACT — definition/key characteristics

What it isA multidisciplinary team-delivered bundle of services for individuals with severe, persistent symptoms from a serious mental illness

GoalsMitigate symptoms, support recovery, increase functioning and symptom management, decrease hospitalizations and crises

DeliveryServices delivered in office and in the person’s natural environment to optimize engagement and promote wellness, self-management, resiliency, and use of natural supports

Admission key requirementMinimum LOCUS or CALOCUS composite score of >= 17 required for initiation

CST — definition/key characteristics

What it isA multidisciplinary team-delivered bundle of services for individuals with moderate to severe symptoms from a serious mental illness

Level-of-Care Specific Criteria

Assertive Community Treatment (ACT) — level-of-care criteria (top-level nodes present in source)

ACT level-of-care criteria (top-level): Admission: DSM psychiatric diagnosis causing severe/persistent symptoms; LOCUS/CALOUS >= 17; willing to accept ACT; less intensive treatment ineffective or inappropriate AND at least 3 risk/complexity indicators present. Continuing stay: meets initiation severity; services necessary to sustain gains; individualized planning; appropriate mode/intensity/frequency; active treatment with progress or adjustments; member participation and willingness to continue. Discharge: treatment goals met; consent withdrawn; no longer meets initiation criteria or meets other level criteria; not engaged despite attempts.

Community Support Team (CST) — level-of-care criteria (top-level nodes present in source)

CST level-of-care criteria (top-level): Admission: DSM psychiatric diagnosis with LOCUS/CALOUS 14-20 causing moderate-severe symptoms; willing to accept CST; outpatient treatment ineffective or inappropriate AND at least 3 specified indicators present. Continuing stay: meets initiation severity; services necessary to sustain gains; individualized planning; appropriate mode/intensity/frequency; active treatment with progress or adjustments; member participation and willingness to continue. Discharge: treatment goals met; consent withdrawn; no longer meets initiation criteria or meets other level criteria; not engaged despite attempts; or significant symptom increase with decreased functioning prompting transition to ACT.

Team-Based Multidisciplinary Services

Team-based multidisciplinary services — single top-level node describing bundles

Service delivery settings: Services delivered in office and in the person's natural environment to optimize engagement and promote wellness, self-management, resiliency and use of natural supports

Policy Summary

PayerOptum

PolicyMedical Necessity for Serious Mental Illness Under Age 26

Policy CodePolicy BH803!L052025

Change TypeNo material change

Effective DateMay 1, 2025

Next Review Date

Key ActionVerify member eligibility, member-specific benefits, and applicable state regulatory requirements before applying these clinical criteria.

SourceLink

On This Page

Time since first psychotic episode (exclusion threshold)

DefinitionTime since first psychotic episode

Exclusion threshold> 18 months = exclusion for CSC eligibility

Documentation requirementReviewers should document timing of first psychotic episode to determine CSC appropriateness

Document prior outpatient treatments attempted (therapy, medication management, case management) and outcomes or reasons why they were inappropriate

For ACT and CST: show evidence that less intensive treatment did not improve symptoms OR was clinically inappropriate

For CSC: confirm willingness to accept services and that criteria for first episode timing are met (see documentation requirements)

Denial Risk

Supporting documentation and exclusion triggers

For specialty care for first-episode psychosis (CSC), include documentation that establishes timing of the first psychotic episode and the diagnostic basis for psychosis. Services are inappropriate if the first psychotic episode occurred more than 18 months prior or if primary symptoms are due to excluded conditions.

Date and clinical description of first psychotic episode (must be within 18 months for CSC eligibility)
Diagnostic evidence supporting psychotic disorder per DSM criteria
Documentation that symptoms are not primarily due to intellectual disability, neurodevelopmental/neurocognitive disorder, substance-related/induced disorder, personality disorder, brain injury, or transient causes (e.g., sleep deprivation)
If first psychotic episode > 18 months, note that CSC is not appropriate

GoalsMitigate symptoms, support recovery, increase functioning and symptom management, decrease hospitalizations and crises

DeliveryServices delivered in office and in the person’s natural environment to optimize engagement and promote wellness, self-management, resiliency, and use of natural supports

Admission key requirementLOCUS or CALOCUS composite score 14–20 required for initiation

CSC — definition/key characteristics

What it isA multidisciplinary team-delivered bundle of services for individuals experiencing a first episode of psychosis and their families

GoalsMitigate psychosis symptoms, support recovery, increase functioning and symptom management, decrease hospitalizations and crises

DeliveryServices delivered in office and in the person’s natural environment to optimize engagement and promote wellness, self-management, resiliency, and use of natural supports

Age window for initiationDesigned for individuals experiencing first-episode psychosis (CSC initiation criteria reference age 14–25)

Duration since first psychotic episode — definition of >18 months

Meaning of >18 monthsRefers to an individual having experienced a first psychotic episode more than 18 months prior to evaluation

ImplicationIf first episode occurred >18 months ago, CSC is not appropriate (exclusion)

Provider actionDocument timing of the first psychotic episode to verify eligibility for CSC

Primary origin exclusions — intellectual disability, neurodevelopmental/neurocognitive, substance-related/induced

Excluded primary originsIntellectual disability; neurodevelopmental or neurocognitive disorder; substance-related or -induced disorder

Other exclusions notedPersonality disorder or brain injury may also indicate symptoms primarily originate elsewhere and exclude CSC/ACT/CST appropriateness

DocumentationDiagnostic basis should be documented to demonstrate symptoms are not primarily due to these excluded conditions

Sleep deprivation–related psychosis exclusion

DefinitionRapid onset psychosis due to sleep deprivation not associated with another psychotic disorder

ExclusionSuch sleep deprivation–related psychosis is excluded from CSC (and noted as inappropriate for ACT/CST when applicable)

DocumentationReviewers should document that psychosis is not attributable solely to sleep deprivation when assessing eligibility

Coordinated Specialty Care (CSC) for First Episode Psychosis — level-of-care criteria (top-level nodes present in source)

CSC level-of-care criteria (top-level): Admission: age 14-25; first significant psychosis symptoms within last 18 months; willing to accept CSC services. Continuing stay: meets initiation severity; services necessary to sustain gains; individualized planning; appropriate mode/intensity/frequency; active treatment with progress or adjustments; member participation and willingness to continue. Discharge: treatment goals met; consent withdrawn; no longer meets initiation criteria or meets other level criteria; not engaged despite attempts.