Optum Coverage Criteria
Latest Optum coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Applied Behavior Analysis (ABA) — New Mexico MedicaidState-specific clinical criteria for coverage, authorization, and delivery of ABA services for New Mexico Medicaid members, including eligibility, provider requirements, and stage-based evaluation and treatment processes.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-15Updated Clinical Criteria for ABA and TMS ServicesDefines the clinical guidelines Optum will use to determine medical necessity for Applied Behavior Analysis (ABA) and Transcranial Magnetic Stimulation (TMS) for Commercial members in Colorado beginning May 15, 2026.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Adult Rehabilitative Mental Health Services (ARMHS), Children's Therapeutic Support Services (CTSS), and Targeted Case Management (MH-TCM) — Minnesota supplemental clinical criteriaState-specific supplemental clinical criteria governing provision, authorization, documentation, and billing of Adult Rehabilitative Mental Health Services for Minnesota Medical Assistance members covered by Optum behavioral health plans.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Hawaii Medicaid Supplemental Clinical Criteria — Applied Behavior Analysis (ABA)State-specific supplemental clinical criteria governing coverage, prior authorization, delivery, and administrative requirements for ABA services for Hawaii Medicaid (EPSDT-eligible) members, including screening, diagnosis, assessment, treatment planning, and provider credentialing.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01New Jersey Medicaid Supplemental Clinical Criteria — Behavioral HealthState-specific clinical criteria and coverage rules for behavioral health services under New Jersey Medicaid (NJ Family Care/Medicaid) for Optum-managed plans, addressing developmental services for Autism Spectrum Disorder (ASD), adult mental health rehabilitative services, provider qualifications, coding, and related clinical guidance.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Transcranial Magnetic Stimulation (TMS) Coverage CriteriaThis policy governs medical necessity criteria, utilization management, coding, and exclusions for TMS treatment of major depressive disorder for Optum members across lines of business. It affects providers who order, supervise, or administer TMS and payers adjudicating coverage.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Alternate Level of Care (ALOC) for behavioral health inpatient stays - New York MedicaidState-specific supplemental clinical criteria for New York Mainstream Medicaid adults and children regarding Alternate Level of Care (ALOC) placement, admission, continued stay, and discharge criteria for behavioral health inpatient services; used by Optum for medical necessity determinations and reimbursement decisions.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-01Kansas Medicaid Supplemental Clinical CriteriaState-specific supplemental clinical criteria used by Optum Behavioral Health Solutions for medical necessity determinations for Kansas Medicaid behavioral health services; applies to providers and reviewers making coverage decisions for covered members in Kansas.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-01New York Medicaid and Essential Plan: Transcranial Magnetic Stimulation (TMS) - Medicaid, Child Health Plus and Essential PlanState-specific supplemental clinical criteria governing coverage and medical necessity determinations for TMS for New York Medicaid, Child Health Plus, and Essential Plan members; applies to providers requesting authorization for TMS services under those programs.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Assertive Community Treatment (ACT) — Idaho Medicaid Supplemental Clinical CriteriaState-specific supplemental clinical criteria governing medical necessity, admission, continuation, discharge, provider qualifications, and exclusions for Assertive Community Treatment services for Idaho Medicaid members under Optum-managed behavioral health plans.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Family-based Intensive Treatment (FIT) coverage criteria for Medicaid membersDefines coverage, prior authorization, billing, and operational requirements for Family-based Intensive Treatment (FIT) for Medicaid members under age 21 at acute risk of hospitalization or recently hospitalized, effective October 1, 2025. Applies to providers delivering FIT in the specified state program.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Idaho Medicaid Plus — Assertive Community Treatment (ACT) Supplemental Clinical CriteriaState-specific clinical criteria for Assertive Community Treatment services used to determine medical necessity for Idaho Medicaid Plus members managed by Optum Behavioral Health Solutions.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Rhode Island Medicaid Supplemental Clinical Criteria — Behavioral HealthState-specific clinical criteria for behavioral health services under Rhode Island Medicaid managed by Optum, governing medical necessity determinations and program requirements for covered behavioral health services and specialized programs.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Supplemental Clinical Criteria: Optum Psychological and Neuropsychological TestingAll Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Supplemental Clinical Criteria: Psychological and Neuropsychological TestingSupplemental clinical criteria governing provider qualifications, coverage rationale, limitations, and developmental/automated testing guidance for psychological and neuropsychological testing for behavioral health benefit plans managed by Optum; applies to reviewers and providers when determining coverage and prior authorization. Does not apply to Department of Managed Health Care-regulated Commercial Health Plans in California.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-16Opioid Treatment ProgramsDefines medical necessity, coverage indications, assessment, testing, providers, and documentation expectations for outpatient opioid treatment programs for Medicare beneficiaries managed by Optum.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-19Texas Medicaid: Autism Services (Applied Behavior Analysis) Supplemental Clinical CriteriaAll Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-19Texas Medicaid: Autism Services (State‑Specific Supplemental Clinical Criteria)State-specific supplemental clinical criteria governing Medicaid-covered autism services, including Applied Behavior Analysis (ABA), for Texas children and youth (age ≤20) and requirements for prior authorization and documentation.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-01Ohio Medicaid Supplemental Clinical Criteria — Behavioral HealthState-specific clinical criteria and coverage rules for behavioral health and substance use disorder services for Ohio Medicaid members; used by Optum reviewers and providers to determine medical necessity and service limitations.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-01Applied Behavior Analysis (ABA) — New Mexico Supplemental Clinical CriteriaState-specific supplemental clinical criteria governing medical necessity, provider requirements, prior authorization, and service staging for ABA services under New Mexico Medicaid; applies to members of Optum-managed behavioral health plans in the state. Affects providers (AEPs, BAs, BCaBAs, BTs, SCPs) and families seeking ABA services.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-01Arizona Medicaid Supplemental Clinical Criteria — Behavioral HealthState-specific supplemental clinical criteria for behavioral health services under Arizona Medicaid managed by Optum, describing medical necessity, provider qualifications, and prior/continued authorization requirements for covered behavioral health programs and services.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-05-01Illinois Commercial Supplemental Clinical Criteria: Medical Necessity for Serious Mental Illness Under Age 26State-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.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01IV Ketamine Infusion Therapy — Coverage Criteria (ForwardHealth)Governance of coverage, prior authorization, provider attestation, allowable settings, and billing submission processes for IV ketamine infusion therapy for members with major depressive disorder under Optum/UnitedHealthcare Community Plan (applies to ForwardHealth/BadgerCare Plus/Wisconsin Medicaid SSI).All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Kentucky Medicaid Supplemental Clinical Criteria — Behavioral HealthState-specific clinical criteria and service requirements for behavioral health services under Optum Medicaid in Kentucky, governing medical necessity determinations and provider-level service delivery for covered behavioral health programs and levels of care.All Optum updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Louisiana Medicaid Applied Behavior Analysis (ABA) - State-Specific Clinical CriteriaState-specific clinical criteria governing medical necessity, prior authorization, assessment, treatment planning, supervision, service delivery, limitations, and telehealth for ABA services for Louisiana Medicaid beneficiaries under age 21.All Optum updates
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Tool Description
Search Optum coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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