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Inpatient and Outpatient Mental Health
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Defines UnitedHealthcare West coverage, medical necessity, and regulatory requirements for inpatient and outpatient mental health and substance use disorder services, including California-specific mandates; applies to plan administration and provider interactions.
Revised language pertaining to California Health and Safety Code Sections 1374.72 and 1374.73.
Revised language pertaining to the California Health and Safety Code, Sections 1374.72 and 1374.73.
Archived previous policy version BIP100.M.
Coverage Criteria and Scope
inv-01: Covered when meeting medical necessity and statutory requirements
Covered when services meet applicable statutory medical necessity and parity standards.
See Federal Mental Health Parity (H.R.1424) and CA HSC sections 1374.72/1374.73.
Medical necessity determinations for service intensity, level of care placement, continued stay, and transfer/discharge follow statutory requirements.
Treatment plans must be made available to the plan upon request; plans must not be used to reimburse respite/daycare/education or parent payment for participation.
A health care service plan shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program (for example, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance). The plan must not include or enforce contract terms that exclude otherwise covered benefits on the basis that those services should or could be covered by a public entitlement program.
If there is a discrepancy between this policy and the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB), the member's EOC/SOB provision governs. Verify member-specific coverage eligibility, limitations, and exclusions in the EOC/SOB and the behavioral health Supplement to the EOC before rendering services.
This policy does not list specific non‑medically‑necessary (NMN) conditions. Providers and reviewers should refer to the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB) and the behavioral health Supplement to the EOC for plan‑specific exclusions and definitions of noncovered services.
Services that are not medically necessary are not covered under this policy. Determinations of medical necessity must align with the member's EOC/SOB provisions and accepted standards of care; documentation should support the medical necessity of services delivered.
Coding and Administrative Details
| No codes listed |
Provider Responsibilities and Utilization Management
Utilization review and prior authorization may be required
The plan may require utilization review and prior authorization that is prospective, concurrent, or retrospective; utilization review may approve, modify, or deny services based in whole or in part on medical necessity.
- Utilization review is an evaluation of existing treatment to ensure proper care at the proper time.
- Utilization review may be used before, during, or after the provision of services.
Confirm plan-specific prior authorization in EOC/SOB
Verify plan-specific prior authorization requirements in the member's Evidence of Coverage/Schedule of Benefits before providing services; some benefits and services may require prior authorization per the member's plan provisions.
- Confirm prior authorization requirements and processes in the member's EOC/SOB prior to rendering services.
Utilization management techniques permitted per plan
Use of utilization management techniques (case management, network providers, utilization review, prior authorization, copayments) is permitted for the provision of required benefits provided they comply with statutory requirements.
- Techniques may be applied so long as they are consistent with applicable law and the plan contract.
Follow EOC/SOB and statutory provider requirements
Providers must follow any additional provider-impact rules and plan provisions in the member's EOC/SOB and comply with statutory requirements when delivering mental health and behavioral health services.
- If there is any discrepancy between this policy and the member's EOC/SOB, the EOC/SOB governs.
Prescribe and document behavioral health treatment plans (including autism)
Behavioral health treatment (including autism services) must be prescribed by a licensed physician or developed by a licensed psychologist, provided under a treatment plan prescribed by a qualified autism service provider, and administered by qualified providers or supervised staff.
- Treatment plan must have measurable goals over a specific timeline and be reviewed no less than once every six months and modified when appropriate.
- Plan must describe impairments, intervention type, number of hours, parent participation, frequency of progress evaluation, and be made available to the plan upon request.
Ensure documentation supports medical necessity and follow EOC/SOB
Providers must follow the member's Evidence of Coverage/Schedule of Benefits and ensure documentation supports medical necessity; documentation should be made available to the plan upon request.
- Documentation should demonstrate clinical appropriateness in type, frequency, extent, site, and duration.
- For autism services, the treatment plan itself must be available to the health care service plan upon request.
Arrange out‑of‑network coverage when in‑network access is not timely/available
If services are not available in-network within applicable geographic and timely access standards, the plan must arrange coverage to ensure delivery of medically necessary out‑of‑network services and the enrollee's cost‑sharing is no greater than for in‑network services.
- Failure to meet timeliness/access standards may trigger the plan to arrange out-of-network options for the enrollee.
Denial risk for non‑medical necessity or EOC/SOB conflicts
Coverage may be denied if services are not medically necessary or if they conflict with the member's Evidence of Coverage/Schedule of Benefits.
- Verify medical necessity and conformity with the member's EOC/SOB to avoid denial.
Background and Regulatory Context
Background: This policy incorporates federal Mental Health Parity requirements and California statutory provisions to ensure parity and appropriate coverage for mental health, substance use disorder, and autism‑related behavioral health services. Covered benefits are organized into Federal/State Mandated Regulations, State Market Plan Enhancements, and Covered Benefits, and all services must be medically necessary. Providers must consult the member's EOC/SOB for plan‑specific provisions and follow applicable statutory requirements referenced in the policy.
Key Definitions
Level of Care — Inpatient, Residential, PHP, IOP, Outpatient
Autism and ABA Treatment Criteria
inv-21: Autism/ABA treatment criteria — requirements for applied behavior analysis and behavioral interventions for autism
Requirements for applied behavior analysis and behavioral interventions for autism.
See definitions of qualified providers in CA HSC and Business and Professions Code.
Plan not to be used for respite/daycare/education reimbursement; must be available to the plan upon request.
Treatment Modalities and Evidence-Based Interventions
inv-22: ABA / evidence-based behavioral interventions
Treatment must meet criteria in CA HSC 1374.73(d) including prescriber, qualified provider, measurable goals, and periodic review.
Visit Limits and Duration
Revision History and Policy Changes
Policy BIP100.N effective 08/01/2026 with revised language pertaining to California Health and Safety Code Sections 1374.72 and 1374.73; supporting information archived and previous policy version BIP100.M superseded/archived.
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