CurrentRegencePolicy 36

Mental Health and Eating Disorders

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This policy establishes medical necessity criteria, treatment expectations, level-of-care requirements, and documentation requirements for mental health and eating disorder services. It applies to providers seeking initial or continued authorization for acute inpatient, residential, partial hospitalization, and intensive outpatient services.

Policy Summary

PayerRegence

PolicyMental Health and Eating Disorders

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJuly 1, 2026

Last ReviewMay 1, 2026

Next Review DateMay 1, 2027

Key ActionSubmit the applicable Regence Behavioral Health Form for initial requests and the Concurrent Request form for continued stays.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Levels of care addressed

20+ hours/weekPartial hospitalization minimum

9 hours/weekAdult intensive outpatient minimum

6 hours/weekChild/adolescent intensive outpatient minimum

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CurrentRegencePolicy 36

Mental Health and Eating Disorders

Customize your policy alerts

Sign up for regence Policy 36 alerts

Get alerted when Policy 36 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerRegence

PolicyMental Health and Eating Disorders

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJuly 1, 2026

Last ReviewMay 1, 2026

Next Review DateMay 1, 2027

Key ActionSubmit the applicable Regence Behavioral Health Form for initial requests and the Concurrent Request form for continued stays.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Levels of care addressed

20+ hours/weekPartial hospitalization minimum

9 hours/weekAdult intensive outpatient minimum

6 hours/weekChild/adolescent intensive outpatient minimum

Inpatient and residential clinical coverage

Coverage Criteria

Level-of-care assessment framework

Medical necessity determinations use the age-appropriate standardized level-of-care assessment system.

Age-appropriate level-of-care assessment: Use LOCUS for adults, CALOCUS-CASII for children and adolescents ages 6–18, or ECSII for children ages 0–5 to make clinical determinations and placement or service-intensity decisions.Adults; ages 6–18; ages 0–5

The assessment systems are applied to acute inpatient, residential, partial hospitalization, and intensive outpatient services.

Applicable contracts exclude services or procedures considered investigational or cosmetic from coverage. Providers should inform members before rendering these services that they may be financially responsible for the cost.

Residential treatment does not include halfway houses, supervised living, group homes, wilderness courses or camps, Outward Bound, outdoor youth programs, outdoor behavioral programs, boarding houses, or settings primarily focused on self-esteem, leadership skills, or long-term social support needs.

Coding and Program Structure

RevenueRevenue

0124	Psychiatric & Eating Disorder Acute Inpatient

Behavioral health service codesRevenue

1001	Psychiatric & Eating Disorder Residential Treatment
0905	Psychiatric & Eating Disorder Intensive Outpatient Program
0912	Psychiatric & Eating Disorder Intensive Outpatient Program; Psychiatric & Eating Disorder Partial Hospitalization - Less Intensive
0913	Psychiatric & Eating Disorder Partial Hospitalization, High Intensity

Partial Hospitalization

ProgramPartial hospitalization for mental health and eating disorder treatment

Minimum structured programming20 or more hours per week

Diagnostic evaluationA qualified attending provider completes a diagnostic evaluation within 7 days of admission and weekly thereafter

Adult Intensive Outpatient

ProgramIntensive outpatient services for mental health and eating disorder treatment

Adult minimumAt least 9 hours of structured clinical programming per week

Psychiatric evaluationAvailable when clinically necessary

Provider Actions and Documentation

Prior Authorization

Behavioral Health Prior Authorization Forms

Use the applicable Regence Behavioral Health Form for initial requests and the Concurrent Request Regence Behavioral Health Form for continued-stay or concurrent reviews. Use the Stepdown request form for step-down requests at the same facility.

Initial requests: Regence Behavioral Health Form or Stepdown request form.
Continued-stay/concurrent reviews: Concurrent Request Regence Behavioral Health Form.

Documentation Required

Documentation Required for Review

The information below must be submitted for initial and concurrent reviews to determine whether the policy criteria are met. Supporting clinical documentation may be requested when the information in the applicable form is insufficient to determine medical necessity.

Required for initial reviews: applicable request form and supporting clinical information when requested.

Policy Background

This policy addresses mental health and eating disorder treatment across four levels of care: acute inpatient, residential, partial hospitalization, and intensive outpatient services. Medical necessity and placement or service-intensity decisions use age-appropriate standardized assessment systems: LOCUS for adults, CALOCUS-CASII for children and adolescents ages 6–18, and ECSII for children ages 0–5.

Definitions and Assessment Systems

LOCUS

Full nameLevel of Care Utilization System (LOCUS)

DeveloperAmerican Association of Community Psychiatrists

UseUsed to make clinical determinations and placement decisions for adults

CALOCUS-CASII

Full nameChild and Adolescent Level of Care Utilization System and Child and Adolescent Service Intensity Instrument (CALOCUS-CASII)

DevelopersAmerican Academy of Child and Adolescent Psychiatry and American Association for Community Psychiatry

Use and population

Level-of-Care Criteria

Inpatient medical necessity and level-of-care criteria

Acute inpatient services must meet all of the following requirements:

Acute inpatient program requirements: The facility must be an acute general hospital with a psychiatric or eating disorder unit, an acute psychiatric or eating disorder hospital, or a freestanding acute inpatient psychiatric or eating disorder facility; it must be capable of secure care, de-escalation, isolation when needed, and involuntary care or immediate referral for involuntary care.24-hour clinical services, monitoring, and observation

Psychiatric, nursing, and medical services must be available on site or close enough for rapid response.

Ongoing inpatient capability: Clinical services, monitoring, and observation remain available 24 hours a day, seven days a week, with psychiatric, nursing, and medical services available on site or close enough for rapid response.24 hours/day, 7 days/week

A qualified attending provider completes a psychiatric diagnostic evaluation within 24 hours of admission and daily thereafter.

Treatment Modalities

Mental health and eating disorder program treatment

Mental health and eating disorder programs are expected to provide all of the following:

Core program treatment expectations: Programs are expected to provide psychiatric evaluation and availability appropriate to the level of care, individual therapy at least weekly or more often when clinically indicated, laboratory or urinalysis testing upon admission and as clinically indicated, individualized treatment and discharge planning, and appropriately credentialed interdisciplinary staffing.At least one individual counseling session per week unless more is clinically indicated

For children and adolescents, family treatment is part of the treatment plan unless contraindications are documented; family assessment is completed within five days of admission and family sessions occur at least weekly or more often when indicated.

Eating disorder nutritional treatment

Eating disorder programs are expected to meet the following nutritional treatment requirement:

Eating disorder nutritional planning:

Policy Summary

PayerRegence

PolicyMental Health and Eating Disorders

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJuly 1, 2026

Last ReviewMay 1, 2026

Next Review DateMay 1, 2027

Key ActionSubmit the applicable Regence Behavioral Health Form for initial requests and the Concurrent Request form for continued stays.

SourceLink

On This Page

Child/Adolescent Intensive Outpatient

ProgramIntensive outpatient services for mental health and eating disorder treatment

Child/adolescent minimumAt least 6 hours of structured clinical programming per week

Psychiatric evaluationAvailable when clinically necessary

Required for concurrent reviews: Concurrent Request form and supporting clinical information when requested.

Documentation Required

Initial Request Documentation

For an initial authorization request, submit the Initial Request Regence Behavioral Health Form or the Stepdown request form when requesting a step-down at the same facility. If requested by staff, provide supporting clinical documentation, including the following when available.

Initial Psychiatric Evaluation or Intake Assessment.
Nursing Assessment and/or History & Physical, if available.
Additional supporting clinical evidence, such as letters from outpatient providers supporting the requested level of care.
Preliminary Individualized Treatment Plan.

Documentation Required

Continued Stay Documentation

For continued-stay or concurrent review, submit the Concurrent Request Regence Behavioral Health Form. If requested by staff, provide supporting clinical documentation when the form does not contain enough information to determine medical necessity.

Most recent psychiatric evaluation.
MD and/or physician extender notes.
Individual and family therapy notes.
List of current medications.
Individualized Treatment Plan and progress reports.

Denial Risk

Investigational or Cosmetic Services

Contracts exclude services or procedures considered investigational or cosmetic. Providers may bill members for these services and should inform members before rendering them that they are likely to be financially responsible.

Investigational or cosmetic services may be excluded from coverage.
Notify members in advance when they are likely to be financially responsible.

Denial Risk

Excluded Residential Settings

Residential treatment must be provided in a licensed, structured facility with the required clinical services, supervision, and programming. Residential care does not include the following excluded settings or programs.

Halfway houses, supervised living, group homes, or boarding houses.
Wilderness courses or camps, Outward Bound, outdoor youth programs, or outdoor behavioral programs.
Settings primarily focused on self-esteem or leadership skills or on providing a supportive environment for long-term social needs.

Denial Risk

Incomplete Review Documentation

Failure to submit required information may affect the review and decision outcome. Supporting clinical documentation is not always required, but it may be requested when the information received through the applicable form is inadequate to determine medical necessity.

Submit all required information for initial and concurrent reviews.
Respond to requests for supporting clinical documentation to avoid an incomplete review.
Missing information may affect authorization and coverage decisions.

Used to make clinical determinations and provide level-of-service-intensity decisions for children and adolescents ages 6–18

ECSII

Full nameEarly Childhood Service Intensity Instrument (ECSII)

DeveloperAmerican Academy of Child and Adolescent Psychiatry

Use and populationUsed to make clinical determinations and provide level-of-service-intensity decisions for children ages 0–5

Mental Health and Eating Disorders Policy

PolicyMental Health and Eating Disorders policy

ContentProvides treatment and program expectations

PurposeDescribes criteria used to determine medical necessity for mental health and eating disorder services

Residential medical necessity and level-of-care criteria

Residential services must meet all of the following requirements:

Residential program requirements: Treatment must be provided in a licensed facility offering a defined therapeutic course and special programming in a controlled environment with security, supervision, and structure.24-hour clinical services, monitoring, and observation

Psychiatric, nursing, and medical services must be available on site or close enough for rapid response.

Ongoing residential treatment requirements: The program provides on-site individual, group, and family therapy seven days a week and services that facilitate return to community functioning in a less restrictive setting.7 days/week

A qualified attending provider completes a psychiatric diagnostic evaluation within 48 hours of admission and weekly thereafter.

Partial hospitalization medical necessity and level-of-care criteria

Partial hospitalization must meet all of the following requirements:

Partial hospitalization program requirements: The program includes structured clinical programming at the required weekly intensity and provides diagnostic evaluation by a qualified attending provider.20 or more structured clinical hours per week; diagnostic evaluation within 7 days of admission and weekly thereafter

Applies to mental health and eating disorder treatment.

Intensive outpatient medical necessity and level-of-care criteria

Intensive outpatient services must meet all of the following requirements:

Intensive outpatient program requirements: The program includes at least 9 hours of structured clinical programming per week for adults or at least 6 hours per week for adolescents and children. Psychiatric evaluation is available when clinically necessary.Adults: at least 9 hours/week; children and adolescents: at least 6 hours/week

Applies to mental health and eating disorder treatment.

Eating disorder programs are expected to document nutritional planning, including a target weight range and planned interventions by a registered dietitian, in the medical record.

Target weight range and registered-dietitian interventions documented

This is a program guideline for eating disorder treatment.