Optum TRR Adult Mental Health LOC Coverage

Coverage Criteria by Level of Care

inv-01: Level of Care 0: Crisis Services

LOC-0 (Crisis Services) covered when ANY of the following admission conditions are met and managed as specified:

LOC-0 admission: No diagnosis required; ANSA indicates a Recommended Level of Care (LOC-R) of 0 OR ANSA indicates LOC-R of 1,2,3,4,5 or 9 and clinician determines the individual is in crisis.ANSA LOC-R

LOC-0 available at intake for new or unassessed individuals; crisis treatment plan required; LOC-A terminates in 7 days unless reauthorized; crisis services do not require prior authorization but UM must authorize within 2 business days.

inv-02: Level of Care 1M: Medication Management

LOC-1M (Medication Management) covered when ALL of the following are met:

LOC-1M admission criteria: 1) Diagnosis of severe and persistent mental illness (schizophrenia, bipolar disorder, or major depressive disorder) with significant functional impairment (GAF ≤ 50 at intake); 2) Maintained an LOC-R of 1 during all ongoing assessments in the prior 12 months (initial assessments not counted); 3) ANSA scores reveal extreme stability for at least 12 months; 4) No crisis event/decompensation and no inpatient psychiatric hospitalization related to mental condition in the prior 12 months.GAF <= 50; 12 months stability

Medical necessity required for initial authorization; authorization period: 365 days; crisis services authorized as medically necessary within this LOC; utilization guidance per LOC-1M table.

inv-03: Level of Care 1S: Skills Training / Basic Services

LOC-1S (Skills Training / Basic Services) covered when ALL of the following are met:

LOC-1S admission criteria: Individual meets HHSC priority population definition, presents with very little risk of harm, has supports and functioning that do not require higher LOC; must have severe and persistent mental illness with significant functional impairment (GAF ≤ 50) OR may be served in LOC-1S due to lack of capacity at a higher LOC.GAF <= 50

Recovery/treatment plan review required at least every 180 days; authorization at LOC level and medical necessity required prior to service delivery.

inv-04: LOC-1S Initial Admission Criteria

LOC-1S Admission — Covered when ALL of the following are met:

LOC-1S admission: 1) Individual has severe and persistent mental illness (schizophrenia, bipolar disorder, or major depressive disorder); 2) Significant functional impairment (GAF ≤ 50 at intake); 3) May be placed in LOC-1S if eligible for a higher LOC but capacity is unavailable.

Recovery/treatment plan review required at least every 180 days; estimated utilization examples and adjunct services listed in LOC-1S table.

inv-05: LOC-2 Initial Admission Criteria

LOC-2 Admission — Covered when ALL of the following are met:

LOC-2 admission criteria: 1) Diagnosis of Major Depressive Disorder (with or without psychosis); 2) MDD with GAF ≤ 50 at intake and significant residual symptoms; 3) ANSA indicates LOC-R of 2; 4) Individual presents very little risk of harm, has supports, and functioning does not require more intensive care.GAF <= 50

Recovery/treatment plan review required at least every 180 days; authorization period 180 days with utilization standards (standard ~3.25 hrs/mo; high need ~5.5 hrs/mo).

inv-06: Discharge Criteria (LOC-1S and LOC-2)

Discharge supported when ANY of the following are met:

LOC discharge indicators: 1) Documentation indicates individual has obtained maximum benefit from LOC; 2) Individual not receptive to treatment after reasonable engagement efforts and not at risk if treatment suspended; 3) Individual withdraws or requests discharge or moves out of service area; 4) Community resources identified and referral completed.

For LOC-2: meeting psychotherapy objectives or refusing psychotherapy may support discharge; refusal usually results in transfer to LOC-1S unless contraindicated.

inv-07: LOC-3 Admission Criteria

Admission criteria to Level of Care:

LOC-3 Admission: Individual determined to have severe and persistent mental illness (schizophrenia, bipolar disorder, or major depressive disorder +/- psychosis), experiencing significant functional impairment, with QIDS >=16 and GAF ≤ 50 at intake; ANSA indicates LOC-R of 3; priority population overrides may apply.QIDS>=16; GAF<=50

Medical necessity required prior to service delivery; recovery/treatment plan review at least every 180 days.

ANSA/Override: ANSA indicates LOC-R of 3 OR individuals meeting priority population with GAF ≤ 50 may be overridden into services when override criteria are met.GAF<=50

inv-08: Service Components and Utilization

Service utilization and components (LOC-2 overview; representative entries):

Core and Adjunct Services: Core services are identified by the uniform assessment and indicated in the recovery/treatment plan; adjunct services provided when clinically appropriate. Examples include CBT (individual/group), CPT, pharmacological management, case management, medication training & support, skills training, supported employment/housing, peer support, flexible funds/community supports, SBIRT, and crisis services.Authorization period 180 days

Per LOC tables, core and adjunct services have specified unit types and estimated utilization.

Estimated utilization LOC-2: Standard therapeutic: 3.25 hours/month; High need therapeutic: 5.5 hours/month; services have specified unit-hour conversions (see LOC-2 table entries).see table entries

Authorization period 180 days

Estimated utilization LOC-3:

inv-09: LOC-4 / ACT Admission

Admission criteria to be met (LOC-4/ACT):

LOC-4 admission criteria: Individual must have severe and persistent mental illness (schizophrenia, bipolar disorder, or major depressive disorder with psychosis) with significant functional impairment (GAF ≤ 50 at intake); ANSA indicates LOC-R of 4. Individuals meeting priority population/GAF ≤ 50 may be overridden into services when criteria met.GAF <= 50

Admission requires all conditions; medical necessity and LOC-level authorization required prior to service delivery; recovery/treatment plan review at least every 180 days.

inv-10: LOC-3 Utilization

Service utilization guidance (LOC-3):

LOC-3 utilization examples: Core and adjunct services should be delivered; examples include Standard Therapeutic ~5.87 hrs/month or High Need ~20.35 hrs/month; Cognitive Processing Therapy standard duration 12 sessions with specified event/unit mappings; day programs, residential treatment and other services have unit-type guidance.authorization 180 days

Utilization values are illustrative and population-based; see LOC-3 table for per-service unit conversions.

inv-11: LOC-4 Utilization

Service utilization guidance (LOC-4):

LOC-4 utilization examples: Core and adjunct services should be delivered; Standard Therapeutic ~10 hrs/month and High Need ~26.65 hrs/month; specific hourly/unit guidance provided for psychosocial rehabilitative services, supported housing, medication training/support and others.authorization 180 days

Per LOC-4 tables, unit-hour and event mappings defined for billing and authorization.

inv-12: Level of Care (LOC-5) Admission Criteria

Admission criteria to LOC-5 — ANY of the following must be met:

LOC-5 admission: Discharged from LOC-0 or released from hospital and not eligible for ongoing services and needs more than crisis services to stabilize.

LOC-5 admission: Discharged from LOC-0 or released from hospital and eligible for ongoing services but ongoing services not available or provider difficulty engaging individual; needs transitional services.

LOC-5 admission: Identified as high-need population (e.g., homelessness, substance use, primary healthcare needs, criminal justice history) and not eligible for ongoing services but needs more than crisis services to stabilize.

LOC-5 admission: High-need individual eligible for ongoing services but ongoing services unavailable or provider difficulty engaging individual; needs transitional services.

inv-13: Continued Stay / Review Criteria for LOC-5

Continued stay and indications for change:

Continued stay: LOC-5 authorizations terminate in 90 days; if eligibility criteria are met, continued services may be provided in LOCs 1S-4 or LOC-0.90 days

If additional LOC-5 beyond initial 90 days required, new recovery/treatment plan required for each authorization period.

Increased LOC indication: Potential increase in LOC indicated if individual's condition worsens as shown by a LOC-R of 0-4 on ANSA.

inv-14: Discharge Criteria from LOC-5

ANY of these indicators would support discharge from LOC-5:

Discharge - higher LOC: Referred to a higher LOC for crisis management (e.g., inpatient psychiatric hospitalization).

Discharge - transitioned: Identified crisis resolved and individual engaged and transitioned to LOC-1S-4.

Discharge - waiting list: Identified crisis resolved but resources do not support placement in LOC-1S-4; individual placed on waiting list for LOC-1S-4.

Discharge - referred: Individual referred and linked to community resources outside the HHSC system.

Discharge - terminates:

inv-15: Adjunct Service Criteria — Cognitive Processing Therapy (CPT)

CPT coverage and continuation rules:

CPT indication: Cognitive Processing Therapy (CPT) is clinically indicated when there is a diagnosis of PTSD.

CPT must be provided by LPHA trained in CPT or equivalent certification.

CPT continuation: Continue CPT if individual has not completed all 12 protocol sessions unless they request discontinuation; continuation appropriate if condition worsens and higher LOC is needed provided individual willing to continue.12 sessions

A discretionary 13th follow-up session recommended about one month after completion.

CPT discontinuation: Discontinue or re-evaluate CPT if individual has not made progress in symptoms or cognition after several sessions; consider alternative treatments.

Document reassessment and reasoning in the record.

inv-16: LOC-EO Admission Criteria

Admission criteria for LOC-EO (Early Onset)

LOC-EO admission: Individual must be 15-30 years old AND have a diagnosis containing psychosis first given within the last two years AND live in the service area of a pilot site.

Enrollment beyond 36 months supports transition/discharge; CSC team model applies.

inv-17: LOC-TAY Admission Criteria

Admission criteria for LOC-TAY (Transition Age Youth)

LOC-TAY admission: Person must be between ages 18 and 20 AND have involvement in one or more systems of care (e.g., juvenile/criminal justice, foster care, family protective services, school 504, alternative education, SUD services, chronic medical services, community mental health) AND have one or more strengths domains (family, social connectedness, optimism, educational, job history, community connection, natural supports).

Authorization period typically 180 days; recovery plan reviewed every 180 days.

inv-18: Discharge Criteria

Discharge/transition criteria (examples across LOCs)

Discharge/transition triggers: Move outside geographic service area OR determined not to have qualifying diagnosis OR enrolled in LOC-EO for 36 months OR determined not to meet age requirement (LOC-EO); for LOC-TAY, move outside service area OR recommended for higher LOC OR no longer meet age requirement; refusal of all services supports discharge.

Providers should facilitate referral when possible; refusal/non-compliance with one service does not preclude other services per TAC.

inv-19: Utilization Standards

Utilization standards (Average Monthly Utilization) for LOC-EO and LOC-TAY

LOC-EO utilization tiers: Standard therapeutic ~5.87 hours/month and High Need therapeutic ~20.35 hours/month with detailed per-service hour/unit expectations (e.g., individual psychotherapy standard 3 hrs/3 events; high need 4 hrs/16 units).Standard=5.87 hrs/month; HighNeed=20.35 hrs/month

Per-service mappings provided in LOC-EO tables.

LOC-TAY utilization: Standard therapeutic ~7.5 hours/month and High Need ~20.35 hours/month with specified per-service units (e.g., intensive case management standard 4 hrs/16 units; medication training & support mappings).Standard=7.5 hrs/month; HighNeed=20.35 hrs/month

Authorization period commonly 180 days; see LOC-TAY tables for details.

inv-20: Service authorization and utilization standards

Services within the LOC are authorized with average monthly utilization standards; some services have separate standard and high-need hour/unit allocations.

Monthly utilization: The LOC has an Average Monthly Utilization Standard (e.g., 7.5 hrs standard) and certain individuals may be assigned a High Need standard (e.g., 20.35 hrs/month) with specific service-to-unit mappings (examples: pharmacological management .25-.5 hrs per unit; psychotherapy mappings shown per LOC).7.5 hrs standard; 20.35 hrs high need

Per-service authorization units and periods must be used for billing and authorization; crisis services follow LOC-0 guidance.

inv-21: Case management and crisis authorization rules

Rules about concurrent services and crisis availability

Case management concurrency: Routine and Intensive Case Management services are not to be authorized or provided concurrently.concurrent prohibition

Crisis services are authorized as medically necessary and follow LOC-0 utilization guidelines.

inv-22: LOC deviation (LOC-D) authorization criteria

Deviations from recommended LOC (LOC-R) are allowed only for specified reasons and require documentation.

Allowed deviation reasons: Resource Limitations; Individual Refused; Clinical Need; Continuity of Care; Other.N/A

Each reason requires documented justification in the medical record; some LOCs prohibit certain deviations (e.g., no deviations into LOC-1M).

Process for requesting deviation: Complete LOC-D when requesting a deviation from LOC-R for intake or update Uniform Assessment; clinician must provide reason per deviation grid and document in notes.Documentation required

Deviations into certain LOCs may be limited by the deviation grid rules.

inv-23: General service compliance

Coverage and service definitions with implied clinical eligibility and regulatory compliance requirements

Service provision requirements: Services must be provided in accordance with cited Texas regulatory chapters where specified (e.g., 25 TAC Chapter 419 Subchapter L for MH Rehabilitative Services; 25 TAC Chapter 411 Subchapter M for Crisis Stabilization Units).

Providers must follow regulatory standards and documentation requirements; SBIRT providers must maintain proof of >=4 hours training.

Individuals who had an inpatient psychiatric hospitalization related to their mental condition within the previous 12 months are specifically excluded from admission to LOC-1M. This exclusion is part of the LOC-1M admission criteria and must be verified during assessment and prior-authorization reviews.

Refusal or non‑compliance with a single type of service does not, by itself, remove an individual’s eligibility for other services. The policy notes that, in accordance with Texas rule references, an individual who declines or is non‑compliant with one service may still receive other appropriate services if clinically indicated and documented.

If an individual explicitly refuses all services, this supports discharge from the level of care; however, refusal or non‑compliance with a single service does not affect eligibility for other services. Engagement efforts and documentation of attempts to provide or offer services must be recorded when services are refused.

When an individual moves outside the geographic service area of an ACT or CSC team, discharge or transition is supported. The team is required, to the extent possible, to facilitate referral to a provider capable of addressing the individual’s needs and to document the referral and transition arrangements in the record.

Use of LOC‑0 is limited to individuals who are newly admitted to services or to those who have been transitioned or discharged from LOC‑5 and who are experiencing a crisis. LOC‑0 authorizations are intended to be brief (they terminate in 7 days unless reauthorized) and are not for ongoing stabilization beyond immediate crisis management.

Assignment to LOC‑EO is contingent on meeting the specified age and psychosis‑timing criteria; if the individual is determined not to have a qualifying diagnosis or does not meet the timing/age requirements, the individual must be transitioned to the next most appropriate level of care.

The policy disallows deviations into LOC‑1M from other LOCs. The deviation grid explicitly states “No deviations allowed into LOC‑1M from other LOC's,” meaning requests to authorize LOC‑1M when the Recommended Level of Care (LOC‑R) is different will not be permitted.

Flexible Funds are described as a resource of last resort. They are intended to support needs directly related to an individual’s mental illness or recovery/treatment plan and are not to be used for elective changes of residence or other non‑clinical, non‑recovery‑related moves.

Continuation of Cognitive Processing Therapy (CPT) should be reconsidered if the individual has not demonstrated symptomatic or cognitive progress after several sessions. The guidelines call for re‑evaluation of appropriateness of CPT versus alternative treatments before continuing the protocol.

If an individual shows no progress in symptoms or cognition after several CPT sessions, the policy indicates CPT should be discontinued or the individual should be referred to other appropriate interventions. Clinical re‑assessment and documentation are required to support discontinuation or referral.

When progress is not observed after several CPT sessions, the policy requires a re‑evaluation of CPT appropriateness. This re‑evaluation should consider alternative evidence‑based treatments and be documented in the clinical record prior to continuing CPT.

If an individual assigned to LOC‑EO is later determined not to meet the psychosis diagnosis timing or age criteria, assignment to LOC‑EO is inappropriate and the individual must be transitioned or discharged to the most appropriate LOC consistent with the updated diagnosis and eligibility.

The deviation grid lists certain LOC transitions that are explicitly disallowed; deviations that are disallowed by this grid (for example, deviations into LOC‑1M) must not be authorized. Any deviation from the Recommended Level of Care requires documented justification and completion of the LOC‑D process, but cannot contravene LOCs that the grid forbids.

Housing‑related supports without accompanying services cannot be counted as supported housing, and the policy limits the use of Flexible Funds to needs related to the individual’s mental illness or recovery plan. Flexible Funds are therefore restricted and intended only after other resources are exhausted and the use aligns with the recovery/treatment plan.

Authorization, Documentation, and Operational Requirements

Prior Authorization

Authorization and Medical Necessity Required

Authorization and medical necessity must be established at the authorized Level of Care (LOC-A) prior to delivery of services. Medical necessity must be documented for any new/initial authorization and must be reestablished for requests for additional service amounts or any change in authorized level of care. Many LOC-specific services list an authorization period (see LOC tables) and services must adhere to those periods when requesting or providing care.

Establish LOC-level medical necessity before services are delivered.
Reestablish medical necessity for additional units or LOC changes.
Follow LOC-specific authorization periods (e.g., LOC-1M = 365 days; LOC-1S/2/3/4 = 180 days; LOC-5 = 90 days; LOC-0 = 7 days or as noted).

Note

LOC-0 Time-Limited Authorization and Crisis Rules

LOC-0 (crisis/intake) is time-limited: LOC-A 0 is only available at intake for new individuals or those without a current assessment. LOC-0 authorizations terminate in 7 days unless reauthorized; additional authorizations may be given when medically necessary. Crisis Intervention Services do not require prior authorization but must be authorized by UM staff within 2 business days of presentation.

LOC-0 requires no diagnosis for admission but is limited to intake/no current UA.
LOC-0 authorization terminates in 7 days unless reauthorized; further authorizations require documentation of medical necessity.
Crisis Intervention Services do not require prior authorization; UM staff must authorize crisis services within 2 business days.

Prior Authorization

LOC-5 Authorization Period and Crisis Services

LOC-5 authorizations are typically issued for 90-day periods. A Recovery/Treatment Plan is required for LOC-5 and, if an extension beyond the initial 90 days is requested, a new recovery/treatment plan must be completed for each subsequent 90-day authorization. Crisis services that occur during an active LOC-5 authorization are considered part of that LOC-A and should be delivered without changing the LOC.

LOC-5 authorization period: 90 days.
A Recovery/Treatment Plan is required for LOC-5 and must be renewed for each LOC-5 extension beyond the initial 90 days.
Crisis services during LOC-5 are included within the LOC-5 authorization and do not require a LOC change.

Documentation Required

Authorization Period Requirements and Recovery/Treatment Plan Timing

Many LOCs specify authorization periods and recovery/treatment plan review intervals that must be followed. Examples: LOC-1M: authorization period and recovery/treatment plan review = 365 days; LOC-1S, LOC-2, LOC-3, LOC-4, LOC-TAY: authorization period and recovery/treatment plan review = 180 days. Adhere to the per-service authorization periods listed in the LOC tables when requesting prior authorization or submitting claims.

LOC-1M: Authorization Period and Recovery/Treatment Plan review = 365 days.
LOC-1S, LOC-2, LOC-3, LOC-4, LOC-TAY: Authorization Period and Recovery/Treatment Plan review = 180 days.
Follow per-service authorization periods in LOC tables (e.g., many LOC-5 services = 90 days).

Documentation Required

Deviation Documentation Requirement and LOC-D Usage

When the authorized level of care (LOC-A) differs from the Recommended Level of Care (LOC-R), the clinician must complete LOC-D documentation and include a mandatory description of the reason for deviation in the clinical notes. Allowed deviation reasons include Resource Limitations, Individual Refused, Clinical Need, and Continuity of Care, each with specific documentation expectations. Some LOC transitions are restricted or disallowed (see Deviation Grid).

Complete LOC-D when requesting a deviation from LOC-R; include clinician reason and supporting documentation.
Document mandatory description in notes when deviating to a LOC-A lower than LOC-R.
Deviation reasons: Resource Limitations, Individual Refused (with documented informed discussion), Clinical Need (justify per history/needs), Continuity of Care (document circumstances).
Refer to the Deviation Grid for allowed/disallowed deviation paths (certain deviations, e.g., into LOC-1M, are not permitted).

Note

Level-Based Admission Sequencing and Assessment Documentation

Level-based admission sequencing rules: LOC-0 may be used without a diagnosis at intake; LOC-1M and LOC-1S require diagnoses and documentation of functional impairment (e.g., GAF ≤ 50) and stability criteria as specified. Providers must reassess following crisis episodes to determine appropriate ongoing LOC and document ANSA/DSM/GAF results used for LOC determinations.

LOC-0: no diagnosis needed for admission; used at intake or for individuals without a current assessment.
LOC-1M: intended for individuals maintained on medication management with diagnoses such as schizophrenia, bipolar disorder, or major depressive disorder and significant functional impairment (GAF ≤ 50); ANSA/DSM used for LOC determinations.
Providers must reassess after crises to select the most appropriate LOC and document assessment tools (ANSA/DSM/GAF).

Documentation Required

CPT Reassessment and Continuation Evaluation

Cognitive Processing Therapy (CPT) should be re-evaluated if an individual shows no progress after several sessions. If lack of progress is observed, the provider must reassess appropriateness of continued CPT versus alternative treatments and document the clinical rationale in the record.

If no symptom or cognitive improvement after several CPT sessions, re-evaluate appropriateness of CPT.
Document reassessment and clinical justification when transitioning off CPT or changing treatment approach.

Note

LOC-EO Enrollment Duration and Transition Expectation

Enrollment limits and exceptional continuity: individuals enrolled in LOC-EO beyond 36 months is an indicator supporting transition/discharge — enrollment beyond 36 months should be used to support transition planning and discharge rather than ongoing indefinite enrollment.

An individual enrolled in LOC-EO for a total of 36 months supports transition/discharge planning.
Use extended enrollment data to document transition readiness rather than continued indefinite authorization.

Key Definitions

Recovery (SAMHSA)

SAMHSA recovery definitionRecovery is a process of change through which individuals improve health and wellness, live a self-directed life, and strive to reach their full potential.

Recovery dimensions (summary)SAMHSA identifies four recovery dimensions: Health, Home, Purpose, and Community, which frame TRR service goals.

TRR orientationTRR applies SAMHSA concepts to support resilience and recovery across community mental health services in Texas.

ANSA, LOC-R and LOC-A relationship

ANSA roleThe Adult Needs and Strengths Assessment (ANSA) establishes a Recommended Level of Care (LOC-R) used for admission and planning.

LOC-R vs LOC-AUtilization Management Guidelines (UM Guidelines) use ANSA/LOC-R together with clinical documentation to determine the Authorized Level of Care (LOC-A).

Documentation and plan linkageCore and adjunct services are identified by the uniform assessment and indicated in the recovery/treatment plan linked to LOC determinations.

LOC admission criteria summary

LOC-1S admission examplesAdmission to LOC-1S requires severe and persistent mental illness (schizophrenia, bipolar disorder, or MDD) and significant functional impairment (GAF <= 50 at intake).

LOC-2 admission examplesLOC-2 admission includes Major Depressive Disorder (with or without psychosis), GAF <= 50 at intake, residual symptoms, and ANSA indicating LOC-R of 2.

Capacity noteIndividuals eligible for a higher LOC may be served in LOC-1S due to lack of capacity at higher LOCs.

Priority population / severe and persistent mental illnesses

Priority population examplesPriority population includes individuals with diagnoses such as schizophrenia, bipolar disorder, or major depressive disorder (with/without psychosis) experiencing significant functional impairment.

GAF criterionSignificant functional impairment is operationalized as GAF <= 50 at intake for priority populations across LOCs.

Clinical focusServices emphasize stabilization of symptoms, skill training, and increased natural supports for these high-need diagnostic groups.

ACT (Assertive Community Treatment)

ACT definitionAssertive Community Treatment (ACT) is a comprehensive program serving as the fixed point of responsibility for treatment, rehabilitation, and support services for individuals with severe and persistent mental illnesses; integrates clinical and rehabilitation staff in a mobile team.

ACT componentsACT merges psychiatric, substance abuse, employment, and housing expertise, minimizes referrals to other programs, and may include limited group activities to reduce isolation or address substance use.

Urban vs Rural ACTDesignation as Urban or Rural ACT is based on number of LOC-R4 individuals or population density in the service area per rules noted in the policy.

LOC-4 admission criteria

LOC-4 admission summaryAdmission to LOC-4 / ACT requires severe and persistent mental illness (e.g., schizophrenia, bipolar disorder, MDD with psychosis) with significant functional impairment (GAF <= 50) and ANSA indicating LOC-R of 4.

Override possibilityIndividuals meeting priority population with GAF <= 50 may be overridden into LOC-4 when override criteria are met.

Team-based care requirementACT is delivered by an integrated mobile team that provides treatment, rehab, and support services with minimal external referrals.

LOC-5 definition

LOC-5 definitionLOC-5 is a flexible, short-term level of care designed to meet individual needs prior to admission into ongoing services; all services are available and tailored to individual needs.

Authorization periodLOC-5 is available for up to 90 days per authorization; additional LOC-5 beyond initial 90 days requires a new recovery/treatment plan for each 90-day authorization.

Transitional use casesUsed after discharge from LOC-0 or hospital when ongoing services are unavailable or when individuals need transitional services (including high-need populations).

Adjunct Services / Core Services

Core service definitionCore Services are essential services in a level of care expected to be delivered to all individuals to support recovery; exceptions require documentation (e.g., contraindication or refusal).

Adjunct service definitionAdjunct Services are clinically indicated, customized services delivered to support recovery and documented in the recovery/treatment plan.

Authorization linkageWhen a LOC is authorized, all core and adjunct services are also authorized, though some local systems may require additional authorizations for certain services.

LOC-EO

LOC-EO descriptionLOC-EO provides specialized, team-based care (Coordinated Specialty Care teams) for individuals experiencing first-episode psychosis; aims to identify and help individuals early to prevent symptoms from becoming primary in their lives.

Team modelCare is delivered by CSC teams trained in the CSC model to provide clinical and support services efficiently with a recovery focus.

Population variabilityIndividuals in LOC-EO will have diagnoses including psychotic features and vary in need and severity, often entering services for the first time.

LOC-TAY

LOC-TAY age focusLOC-TAY targets transition-age youth (approximately ages 16-20; admission criteria elsewhere specify 18-20) and focuses on transitions to adulthood.

Service componentsLOC-TAY emphasizes intensive case management, evidence-based assessments and treatments, COPSD services when indicated, and supports for education/employment/housing transitions.

Authorization periodAuthorization periods for LOC-TAY commonly are 180 days with recovery plan review every 180 days.

Core Service

Core Service documentation expectationsCore Services must be identified by the uniform assessment (UA) and indicated in the recovery/treatment plan; if not provided due to contraindication or refusal, documentation in the record is required and engagement efforts must be documented.

Service authorization linkCore Services are part of the LOC authorization; per-service authorization units (time, events, dollars) must be used for billing and authorization.

ExceptionsExceptions to delivering core services require justification: UA does not indicate need, clinical contraindication, or documented refusal by the individual.

Adjunct Service

Adjunct Service documentation expectationsAdjunct Services must be clinically indicated, included in the recovery/treatment plan, and documented when authorized and delivered.

CustomizationAdjunct Services supplement Core Services based on individual needs identified in the UA and recovery plan.

Authorization noteWhen a LOC is authorized, adjunct services are authorized as clinically appropriate but some local systems may still require additional authorizations.

Crisis Intervention Services

Crisis Intervention Services definitionInterventions in response to a crisis to reduce symptoms of severe and persistent mental illness and prevent admission to a more restrictive environment; provided per 25 TAC Chapter 419 Subchapter L; does not require prior authorization.

IntentIntended to stabilize acute symptoms quickly and connect individuals to appropriate LOCs and community supports.

Unit/average time noteCrisis Intervention Services typically billed in 15-minute units; average stabilization time ~4.5 hours per crisis episode.

Crisis Stabilization Unit

CSU definitionCrisis Stabilization Unit: short-term residential treatment to reduce acute symptoms in a secure, clinically staffed, psychiatrically supervised environment licensed under Chapter 577 and 25 TAC Chapter 411 Subchapter M.

Max length of stayMaximum length of stay in a Crisis Stabilization Unit is 14 days.

Related servicesCSU admission aligns with other crisis services such as crisis residential treatment and extended observation, with unit type = bed day for stays.

Extended Observation

Extended Observation definitionUp to 48-hour emergency and crisis stabilization service in a secure, clinically staffed environment with access to urgent/emergent medical evaluation and transfer when higher LOC is needed.

Unit typeExtended Observation is billed as a bed day unit (up to 48 hours per episode).

PurposeProvides short-term stabilization and coordination for transfer to higher LOC if indicated.

SBIRT

SBIRT definitionScreening, Brief Intervention and Referral to Treatment (SBIRT) is a public health approach for early intervention for substance use risk; intended for individualized (not group) interventions.

Training requirementProviders who deliver SBIRT must complete at least 4 hours of SBIRT training and maintain proof of training at the provider's place of service.

Unit guidanceSBIRT screening: 0.25 hours with 2 units/year (screening only) or 0.25 hours with 4 units/year (screening + brief intervention); high-need allowances increase encounters up to 4/year.

Detailed Level of Care Criteria

inv-97: LOC-0, LOC-1M, LOC-1S — grouped LOC criteria (top-level nodes supplied from chunks)

LOC grouping - LOC-0/1M/1S: Top-level summary of LOC-0, LOC-1M, and LOC-1S admission/authorization expectations as defined in respective LOC sections (no additional top-level nodes supplied).

See individual LOC blocks for criteria and authorization periods (LOC-0: 7 days default; LOC-1M: 365 days; LOC-1S: 180 days).

inv-98: LOC-1S — dedicated LOC-1S criteria block

LOC-1S detail: LOC-1S admission requires severe and persistent mental illness with GAF ≤ 50; recovery/treatment plan reviewed at least every 180 days; adjunct and core services and estimated utilization per month are specified in LOC-1S tables.GAF <= 50

Adjunct services include CPT (12 sessions), CBT, supported employment/housing, peer support (non-billable), flexible funds, and others per table.

inv-99: LOC-2 — dedicated LOC-2 criteria block

LOC-2 detail: LOC-2 admission requires diagnosis of MDD (with/without psychosis), GAF ≤ 50, ANSA LOC-R=2, and residual symptoms; authorization period 180 days with recovery/treatment plan review every 180 days; utilization standards provided in LOC-2 tables.GAF <= 50

Per-service unit/hour mappings and adjunct services described in LOC-2 tables.

inv-100: Inpatient, Residential, PHP, IOP, Outpatient — LOC boundaries and criteria

LOC-3 boundaries: LOC-3 covers a range of outpatient to intensive outpatient services (Inpatient, Residential, PHP, IOP, Outpatient distinctions apply) for individuals with severe and persistent mental illness and significant impairment; medical necessity and LOC-level authorization required prior to service delivery.QIDS>=16; GAF<=50

Recovery/Treatment Plan review at least every 180 days; utilization guidance per LOC-3 tables.

inv-101: LOC-4 / ACT — criteria for ACT and LOC-4 admissions

LOC-4 / ACT criteria: LOC-4/ACT admission requires severe and persistent mental illness with GAF ≤ 50 and ANSA LOC-R=4; ACT provides a comprehensive mobile team model with integrated clinical and rehabilitation staff; medical necessity and authorization required prior to service delivery.GAF <= 50

Recovery/Treatment Plan review at least every 180 days; utilization standards shown in LOC-4 tables (standard 10 hrs/mo; high need 26.65 hrs/mo).

inv-102: LOC-3 — LOC-3 criteria

LOC-3 criteria: Admission for LOC-3 requires severe and persistent mental illness, significant functional impairment, QIDS >=16 and GAF ≤ 50; ANSA indicates LOC-R=3; medical necessity and LOC-level authorization required.QIDS>=16; GAF<=50

Recovery/Treatment Plan review at least every 180 days; CPT and other adjuncts available as specified.

inv-103: LOC-4 — expanded LOC-4 criteria across multiple chunks

LOC-4 expanded criteria: LOC-4 includes expanded core and adjunct services with specified unit/hour mappings and utilization tiers; authorization period 180 days and recovery/treatment plan review required every 180 days.

Examples: psychosocial rehab individual 5.75 hrs/23 units (standard) to 14.25 hrs/57 units (high need); supported housing and flexible funds unit mappings included.

inv-104: LOC-5 — LOC-5 criteria and authorization notes

LOC-5 criteria and authorization: LOC-5 designed to flexibly meet individual needs prior to admission into ongoing services; all services available in LOC-5 with authorization periods typically 90 days; recovery/treatment plan required and a new plan required for each additional 90-day authorization.90 days

Crisis services are core in LOC-5 and follow LOC-0 utilization rules; per-service unit/event mappings provided for LOC-5 tables.

inv-105: Early Onset (LOC-EO) — LOC-EO criteria

LOC-EO criteria: LOC-EO admission requires age 15-30, psychosis diagnosis first given within last 2 years, and residence in pilot service area; CSC team model delivers coordinated specialty care; enrollment beyond 36 months supports transition/discharge.36 months max

Diagnostic timing and age requirement must be met; if not, transition to appropriate LOC required.

inv-106: Transition Age Youth (LOC-TAY) — LOC-TAY criteria

LOC-TAY criteria: LOC-TAY admission requires age 18-20, involvement in one or more specified systems of care, and at least one strengths domain; authorization period typically 180 days with recovery plan review every 180 days.

Discharge triggers include moving outside service area, recommended higher LOC, or no longer meeting age requirement.

inv-107: LOC-5 (alternate grouping) — LOC-5 elements

LOC-5 overview: LOC-5 is a flexible transitional LOC with services available to meet individual needs; authorization periods commonly 90 days; continued stay and discharge criteria as defined in LOC-5 section.90 days

See LOC-5 tables for per-service units and crisis service availability.

inv-108: Community-based LOC (standard/high-need distinctions)

Community-based LOC admission & utilization: Admission follows ANSA/Uniform Assessment recommendation (LOC-R); average monthly utilization standard often 7.5 hours with high-need allocations up to 20.35 hours/month for specified services.7.5 hrs standard; 20.35 hrs high need

Per-service mappings define units and hours (e.g., intensive case management 4 hrs/16 units standard for TAY).

inv-109: Inpatient, Crisis Stabilization Unit, Crisis Residential, Day Programs — acute-level LOC criteria

Acute-level LOC admission contexts: Day Programs for Acute Needs, Crisis Residential Treatment, Crisis Stabilization Units and Inpatient Hospitalization apply to individuals with acute psychiatric symptoms or risk of harm requiring short-term intensive or 24-hour care; services must follow TAC standards and regulatory maximums (e.g., CSU max 14 days; Extended Observation up to 48 hours).CSU max 14 days; EO up to 48 hours

Inpatient hospitalization must be with a hospital contracting with or operated by the Contractor.

Available Treatments and Modalities

inv-110: Crisis services, Pharmacological Management, Routine Case Management, SBIRT — top-level modality node

Modality: Crisis & pharmacological: Crisis services array, pharmacological management, routine case management and SBIRT described with unit types and authorization guidance; crisis services average stabilization time ~4.5 hours per episode.Crisis avg 4.5 hours

SBIRT training requirement: providers must complete >=4 hours training; crisis services do not require prior authorization.

inv-111: Cognitive Processing Therapy (CPT) — modality details and rules

CPT modality: Cognitive Processing Therapy (CPT) standard duration 12 sessions; indicated for PTSD; continue to completion unless patient requests discontinuation or no progress after several sessions prompts re-evaluation; discretionary 13th follow-up session recommended about one month post-completion.12 sessions

CPT must be delivered by LPHA trained in CPT or equivalent; authorization periods vary (commonly 180 days).

inv-112: Psychosocial and support services — list and conditions for psychosocial/support services

Psychosocial & support services: Core and adjunct psychosocial/support services include pharmacological management, medication training & support, routine case management, skills training & development, supported employment/housing, peer support, flexible funds/community supports, engagement activities, SBIRT and crisis services; unit types and estimated monthly utilization specified by LOC.varies by service

Peer support often non-billable; flexible funds are funds of last resort and not for elective moves unrelated to recovery plan.

inv-113: CPT — further CPT modality references

CPT specifics: CPT standard duration 12 sessions; discontinue or re-evaluate if no symptomatic or cognitive progress after several sessions; CPT may continue into higher LOC if clinically appropriate and patient willing.12 sessions standard

Per LOC tables CPT unit/event mappings differ by LOC (see LOC-3/LOC-4 tables).

inv-114: CBT — cognitive behavioral therapy modality details

CBT modality: Cognitive Behavioral Therapy (CBT) is the selected treatment model for adult counseling services; individual CBT standard duration 16 sessions; must be provided by LPHA or supervised master's-level staff with competency review.16 sessions

Group CBT considered adjunct service; recovery/treatment planning included.

inv-115: CPT — further CPT modality references

CPT continuation guidance: If no progress after several CPT sessions, re-evaluate appropriateness of CPT versus other treatments; continuation may be warranted to complete protocol unless patient requests discontinuation; follow-up session recommended.

Document reassessment and rationale when discontinuing or continuing CPT.

inv-116: CPT — adjunct entries in treatment modalities

CPT clinical rules: CPT indicated for PTSD; standard 12-session protocol; may continue into higher LOC when clinically appropriate and patient willing; 13th follow-up session discretionary approximately one month after completion.12 sessions

CPT delivered by trained LPHA; see LOC tables for session duration (45-60 min) and event/unit mappings.

inv-117: Core and crisis behavioral health services — core services listing and crisis overlap

Core services list: Core services include case management, psychiatric diagnostic interview, pharmacological management, medication training & support, skills training & development, supported employment/housing, flexible community supports, crisis services, psychosocial rehab, peer support, injections administration, family counseling, individual psychotherapy, group counseling, respite, inpatient and crisis residential services.

Core services identified by uniform assessment and indicated in recovery/treatment plan; per-service unit/hour mappings provided in LOC tables.

inv-118: Psychotherapy, CBT, CPT, Crisis services, Crisis residential/stabilization — four top-level modality nodes

Psychotherapy and crisis services: Psychotherapy modalities (CBT, CPT), crisis services, crisis residential/stabilization and day programs defined with regulatory and provider qualifications; SBIRT defined with training requirements and unit mappings.

Providers must meet licensure and competency/training requirements as specified.

inv-119: Rehabilitative and support services — rehabilitative/support service listing

Rehabilitative & support services: Psychosocial rehabilitative services, skills training & development, supported employment/housing, flexible community supports, flexible funds, medication training & support, pharmacological management and psychiatric diagnostic interview are intended to address functional deficits and support recovery; must follow TAC requirements where applicable.

Flexible funds are funds of last resort and not for elective residential moves unrelated to recovery plan.

inv-120: SBIRT — SBIRT modality details

SBIRT requirements: SBIRT must be provided by designated licensed clinicians and intended for individualized intervention (not group); providers must complete at least 4 hours of SBIRT training and maintain proof at place of service; unit mappings defined (.25 hours/2-4 units per year depending on brief intervention).4 hours

High-need allowances increase encounter frequency up to 4 per year for TAY.

Utilization Standards and Visit Limits

Pharmacological Management, SBIRT, Routine Case Management

Pharmacological Management examplesPharmacological Management entries show examples across LOCs: e.g., LOC-1M lists .5 hour = 2 units or .75 hour = 3 units; LOC-TAY/LOC-EO standard = 0.25 hours = 1 unit (high need = 0.5 hours = 2 units).

SBIRT unit examplesSBIRT screening without brief intervention = 0.25 hours/2 units per year; with brief intervention = 0.25 hours/4 units per year (documented in LOC-0/LOC-1M/LOC-4 tables).

Routine Case Management conversionsRoutine Case Management examples include .5 hour/2 units and other conversions across LOCs (see LOC-1M/LOC-1S/LOC-TAY tables for per-LOC mappings).

Therapeutic hours (standard/high-need) — LOC-1S examples

Therapeutic hours (standard) for LOC-1SStandard estimated utilization: 1.3 hours per month (e.g., 0.25 hours = 1 unit conversions shown in LOC-1S tables).

Therapeutic hours (high-need) for LOC-1SHigh-need estimated utilization: 2.25 hours per month (LOC-1S high-need mapping uses .5 hours = 2 units conversions).

Conversion examplesLOC-1S shows Standard 1.3 hrs/mo = .25 hours/1 unit conversions and High Need 2.25 hrs/mo = .5 hours/2 units (also used for routine case management mappings).

Cognitive Processing Therapy

Cognitive Processing Therapy standard durationCognitive Processing Therapy (CPT) standard duration is 12 sessions (noted across LOC tables); documented continuation/discontinuation guidance applies if no progress after several sessions.

Session guidanceSome LOC tables map CPT as 3 hours/3 events or 4 hours/16 events depending on LOC and need tier; a discretionary 13th follow-up session may be offered about 1 month after completion.

Re-evaluation ruleIf no progress in symptoms or cognition after several CPT sessions, CPT should be re-evaluated and may be discontinued in favor of other treatments.

Therapeutic hours (LOC-2 and LOC-3)

LOC-2 therapeutic hours (standard/high)LOC-2 standard therapeutic = 3.25 hours/month; LOC-2 high-need therapeutic = 5.5 hours/month (documented in LOC-2 table).

LOC-3 therapeutic hours (standard/high)LOC-3 standard therapeutic = 5.87 hours/month; LOC-3 high-need therapeutic = 20.35 hours/month (documented in LOC-3 table).

Per-service variabilityPer-service unit/hour mappings vary by LOC and need tier; tables provide examples for psychosocial rehab, case management, pharmacological management, etc.

Therapeutic services / core services (LOC-3/LOC-4 examples)

LOC-3 standard/high need hours per monthLOC-3 Standard = 5.87 hrs/month; LOC-3 High Need = 20.35 hrs/month (used across LOC-3 table entries).

LOC-4 standard/high need hours per monthLOC-4 Standard = 10 hrs/month (examples); LOC-4 High Need = 26.65 hrs/month referenced in utilization guidance tables.

Per-service examplesLOC-3/LOC-4 include service-level hour/unit mappings (e.g., psychosocial rehab individual group hours, medication training & support conversions) to meet monthly totals.

Psychiatric diagnostic interview

Psychiatric diagnostic interview frequencyPsychiatric Diagnostic Interview Examination is typically N/A for monthly mapping and is listed as 1 Event per year for many LOCs (e.g., LOC-1M, LOC-1S, LOC-4, LOC-5, LOC-TAY).

Event unit useThe Psychiatric Diagnostic Interview is billed as an Event unit rather than time-based units in LOC tables.

Authorization period linkageThe psychiatric diagnostic interview event is captured within LOC authorization periods (e.g., 180 or 365 days depending on LOC).

Counseling (CBT - Individual) standard duration

CBT individual standard durationCounseling (CBT - Individual) standard duration is 16 sessions as listed in LOC-5 and other LOC tables.

CPT session length vs CBTCPT session length guidance varies by mapping but CBT individual sessions often follow standard session lengths in LOC tables; CPT sessions documented separately.

Standard session blockCBT standard 16 sessions commonly used as the expected course for individual CBT in adult services.

Counseling (CPT) session length

CPT/Counseling session lengthCounseling (Cognitive Processing Therapy) session length is listed as 45-60 minutes in LOC-5 and related tables.

Per-session billingCPT/Counseling sessions use time-based unit definitions (45-60 min) for per-session billing entries in LOC tables.

ApplicabilitySession length guidance applies across LOCs where CPT/individual counseling is provided (e.g., LOC-3, LOC-4, LOC-5).

SBIRT screening

SBIRT screening unit/timeSBIRT screening without brief intervention = 0.25 hours (15 minutes) with 2 units per year; with brief intervention = 0.25 hours with 4 units per year.

Annual frequency guidanceStandard guidance lists 2 units/year for screening only and 4 units/year when brief intervention is included; high-need allowances may increase encounters (e.g., up to twice or four times/year depending on LOC).

Provider training requirementSBIRT must be delivered by specified licensed clinicians and is intended for individualized interventions (not group).

Various listed services — units/hours per month examples

Monthly utilization varies by service and tierUnits/hours per month vary by service and need tier; examples include Standard ~5.87 hrs/month or 7.5 hrs/month for some LOCs and High Need ~20.35 hrs/month for high-need allocations.

Service-to-unit examplesExamples: Individual Psychotherapy Standard = 3 hours/3 events; High Need = 4 hours/16 units; Intensive Case Management standard = 4 hours/16 units (LOC-TAY).

Flexible funds and community supports mappingFlexible Funds use $1 units; Flexible Community Supports typically map to 15-minute units (15 min = 1 unit) in LOC-4/LOC-5 tables.

SBIRT Screening — frequency and unit guidance

SBIRT screening frequency and units (TAY/EO)SBIRT screening: screening only = .25 hours/2 units per year; screening + brief intervention = .25 hours/4 units per year; high-need tiers permit increased encounters (e.g., twice per year or up to 4 encounters/year as specified for LOC-TAY).

High-need allowancesHigh-need therapeutic tiers may increase SBIRT encounters (e.g., twice per year or four encounters per year depending on LOC and need).

Training reminderProviders must be trained (>=4 hours) to deliver SBIRT and maintain proof of training at place of service.

Crisis Stabilization Unit, Extended Observation

Crisis Stabilization Unit max lengthCrisis Stabilization Unit maximum length of stay is 14 days (licensed and regulated per Chapter 577 and 25 TAC Chapter 411 Subchapter M).

Extended Observation max durationExtended Observation provides up to 48 hours of emergency/crisis stabilization per episode.

Average crisis stabilization timeAverage time to stabilize a crisis episode is approximately 4.5 hours.

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Utilization Management Guidelines: Adult Mental Health Services (TRR Levels of Care)

Coverage Criteria by Level of Care

Service Definitions and Coding Notes

Authorization, Documentation, and Operational Requirements

Policy Background

Key Definitions

Detailed Level of Care Criteria

Available Treatments and Modalities

Utilization Standards and Visit Limits