2023 Medical Necessity Criteria
New Directions Behavioral Health (New Directions) utilizes medical necessity criteria to make medical necessity
determinations. The medical necessity criteria set applied varies according to the behavioral health
service being requested. To determine which criteria set will be used, please refer to the list below:
New Directions administers each benefit as designed by the health plan and set out in the member’s benefit agreement. The presence of a specific level of care criteria within a criteria set does not constitute the existence of a specific benefit. Providers and facilities should verify the member’s available benefits online when available, or by contacting the applicable Customer Service department.
For more information about LOCUS, CALOCUS, ECSII and ASAM, please review the following material:
LOCUS Guide for Patients and Families LOCUS Evaluation Parameters LOCUS Levels of Care CALOCUS Evaluation Parameters CALOCUS Levels of Care ECSII Guide for Patients, Families, and Providers An Introduction to the ASAM Criteria for Patients and Families
- Level of Care Utilization System (LOCUS) will be used to evaluate behavioral health treatment requests for adults age 19+ years
- Child and Adolescent Level of Care Utilization System (CALOCUS) will be used to evaluate mental health treatment requests for children and adolescents ages 6-18 years.
- Early Childhood Service Intensity Instrument (ECSII) will be used to evaluate mental health treatment requests for infants, toddlers and children ages birth through 5 years.
- ASAM Criteria will be used to evaluate substance use disorder service and treatment requests
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New Directions medical policies apply to the following treatments and services, as applicable:
- Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder (ABA for ASD)
- Applied Behavior Analysis for the Treatment of Down Syndrome (ABA for DS)
- Transcranial Magnetic Stimulation (TMS)
- Electroconvulsive Therapy (ECT)
- Psychological/Neuropsychological Testing (PNT)
- 23-Hour Observation
New Directions administers each benefit as designed by the health plan and set out in the member’s benefit agreement. The presence of a specific level of care criteria within a criteria set does not constitute the existence of a specific benefit. Providers and facilities should verify the member’s available benefits online when available, or by contacting the applicable Customer Service department.
For more information about LOCUS, CALOCUS, ECSII and ASAM, please review the following material:
LOCUS Guide for Patients and Families LOCUS Evaluation Parameters LOCUS Levels of Care CALOCUS Evaluation Parameters CALOCUS Levels of Care ECSII Guide for Patients, Families, and Providers An Introduction to the ASAM Criteria for Patients and Families
Copyright 2015 by the American Society of Addiction Medicine. Reprinted with permission.
No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM.