Optum clinical guidelines Guideline Application For medical necessity clinical coverage criteria for Medicare Advantage plans Behavioral Health Plan, California (doing business as OptumHealth Behavioral Solutions of California (“Optum-CA”)). Autism/Applied Behavior Analysis (ABA) Reimbursement Policy – Anniversary Review & Updates 11-20-24. It does not constitute medical advice. , refer to the Optum Behavioral Clinical Policy titled . • • • Description of Service Applied Behavior Analysis (ABA) Related Optum Clinical Guideline • Fertility Solutions Medical Necessity Clinical . P. A diagnostic report completed by a non - QHCP (i. Interim review effective 04/07/2025. which can then be translated into guideline recommendations for clinical practice. Medicare Chiropractic Services – Clinical Guideline Author: Optum Subject: This policy provides the medical necessity criteria consistent with CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30. CPT Code Description ; 96116 ; Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [e. Clinical Guidelines. You can view these guidelines by selecting the Clinical Guidelines and Decision Support References link on this site. leukemia (ALL) and non-Hodgkin lymphoma. It does not constitute This clinical guideline applies only to the state of Ohio. Determinations are subject to any applicable benefit restrictions, state and federal mandates and/or regulations, and documentation of the medical necessity and Optum’s Clinical Submission Process is described in the Optum Provider Operations Manual (www. This information is intended to serve only as a general reference resource regarding Optum’s reimbursement policy for the Related Optum Clinical Guideline Other Policies and Guidelines may apply. A. Summary of UM Program Changes. o Guidelines for All Optum trademarks and logos are owned by Optum, Inc. Clinical studies have shown significant response rates with durable remissions in patients who have been heavily pre-treated (Maude, 2014). This Clinical Guideline is provided for informational purposes. UnitedHealthcare uses evidence -based clinical guidelines from nationally recognized sources during review of our quality and health management programs. Practice guidelines for neuropsychological assessment and consultation. After Hours and Weekend Care - 3-27-25 Anniversary Review. Learn more. g. com, go to Tools and Resources → Policies, Protocols and Guidelines. Request for confidential Optum Infusion Pharmacy communications at an alternative address or by another means. Our innovative clinical content, technologies, solutions, and services have helped reduce the administrative burden, enhance payer-provider relations, and improve care quality. REVISED: 10/15/10 ©2010 OptumHealth Care Solutions – Physical Health. visit www. myoptumhealthphysicalhealth. Q1. Guidelines and Policies. Optum may develop clinical criteria or adopt externally-developed clinical criteria that supersede this American Academy of Clinical Neuropsychology. CMS and contractor web sites and Optum resources to help you in your guidance changes and the latest evidence-based care guidelines? 9. The ASAM Criteria are nationally recognized standards and guidelines developed to support individualized and holistic treatment planning, with a focus on outcomes-driven The Optum “Clinical Support Program” has been designed to assist in the delivery of effective and efficient services emphasizing evidence-informed care. Personal; Business; Our innovative clinical content, technologies, solutions and services have helped our plans and disability carriers. This guideline is applicable to all UM policies. All rights reserved. • Optum periodically audits provider records to ensure compliance with Optum policies and procedures. The Clinical Neuropsychologist 2007; 21(2):209-231. This tool also describes the clinical Related Optum Clinical Guideline • Fertility Solutions Medical Necessity Clinical . When I submit a second Patient Summary Form for the second condition, the first Patient Summary Response is changed to reflect inclusion of the second condition. 6 %âãÏÓ 6254 0 obj > endobj 6274 0 obj >/Filter/FlateDecode/ID[]/Index[6254 34]/Info 6253 0 R/Length 109/Prev 1279236/Root 6255 0 R/Size 6288/Type/XRef/W[1 optum. guideline and the member’s specific benefit, the member’s specific benefit supersedes this guideline. . Add-on Codes - Anniversary review approved 6-27-24. Once implemented, CPGs can help reduce medical errors, improve patient safety and promote accountability for following best practices and standards of care. optum. Members should consult their evidence, prevailing medical standards and clinical guidelines supporting our determinations regarding specific services. This document contains information that is considered proprietary to Optum Rx and should not be reproduced without the express written consent of Optum Rx. The Clinical Validation and Documentation Integrity for Coding is a concise, reliable, and easy-to-follow tool for those problematic diagnoses and PCS inpatient procedures that are most often questioned by payers. Stereotactic body radiation therapy and stereotactic radiosurgery Clinical guidelines Effective January 1, 2023 OptumHealth Care Solutions – Physical Health includes OptumHealth Care Solutions, LLC, ACN Group IPA of New York, Inc. American College of Cardiology/American Heart Association. operating under the brand Optum U. Printed copies are for reference only. An EHR-integrated solution that delivers advanced clinical decision support for guideline-directed, patient The Clinical Sciences Institute. com Insights and Best Practices for Clinical Documentation Improvement Programs In the face of alarming predictions about ICD-10’s administrative impact and its veritable explosion of new codes to wrangle with, and despite the proven positive impact on improving the accuracy of DRG assignment and quality metrics, some hospitals still Related Optum Clinical Guidelines • Chimeric Antigen Receptor T-cell (CAR T) Therapy • Gene Therapy • Solid Organ Transplantation • T-Cell Receptor T-Cell (TCR T) Therapy • Tumor-Infiltrating Lymphocyte (TIL) Cell Therapy ; Medications/Drugs (Outpatient/Part B) Page 2 of 32 %PDF-1. Behavioral Health Services Documentation - Retired 10-7 The following Clinical Practice Guidelines were approved for use by the Clinical Quality and Operations Committee (formerly the Utilization Management Committee, the Behavioral Policy & Analytics Committee, and the Clinical %PDF-1. Please complete and return the form to the requesting department. Applicable Codes . All other trademarks are the property of their respective owners. Guideline: Infertility ; Infertility Diagnosis, Treatment, and Fertility Preservation Page 2 of 23 UnitedHealthcare Oxford Clinical Policy Effective 01/01/2025 ©1996-2025, Congratulations on your decision to join the Optum ABA Network. American College of Cardiology/American Heart Association. We would like to show you a description here but the site won’t allow us. ASAM Level 2. 5 for covered chiropractic services provided to Medicare Advantage members. Skip to main content. 2007. These clinical policies (as developed by us and re vised from time to time), are available to Covered Persons on Optum’s member web site or by calling the telephone number on the Covered Person’s ID card. Other clinical criteria may apply. This guideline addresses the primary prevention of cardiovascular disease in Optum may develop clinical criteria or adopt externally-developed clinical criteria that supersede this guideline when required to do so by contract or regulation. FDA Approvals Lifileucel (Amtagvi™) is a tumor-derived autologous T cell immunotherapy indicated for the treatment of adult patients %PDF-1. Other Policies and Coverage Determination Guidelines may apply. TABLE OF CONTENTS 1 Clinical Performance Guideline Fertility Solutions Infertility www. com). Guideline: Infertility . This unique resource provides the extensive clinical criteria and associated documentation necessary for code assignment. This document is proprietary and confidential to Optum® 2025. Optum reserves the right, in its sole discretion, to modify its clinical criteria as necessary using the process described in Clinical Criteria. NEW Change Effective 11/13/2021: The Optum offers a comprehensive clinical decision support solution designed to strengthen patient outcomes and reinforce appropriate utilization. The Summary of UM Program Changes captures UM recommendations for any new products (molecular entities, formulations, generics,) as well as updates to any existing UM programs. • ® ®Care opportunities: Powered by the Optum Symmetry EBM Connect® engine, Impact Pro can help identify a member’s care gaps and intervention opportunities using a library of over 700 guideline and the member’s specific benefit, the member’s specific benefit supersedes this guideline. Clinical Criteria and Guidelines Includes ASAM Criteria, LOCUS, CALOCUS-CASII, ECSII Criteria, Medicare Criteria, State and Contract Specific Criteria, as well as Optum Behavioral Clinical Policies and Supplemental Criteria. 1, Vol. Any requests for services that are stated as unproven or services for which there is a coverage or quantity limit will be evaluated for medical necessity using Clinical Review Panel of more than 1,100 independent, multidisciplinary experts. Once implemented, CPGs can help reduce This document is proprietary and confidential to Optum®. Resources to assist you in your practice and help your patients are organized by age. Resequencing of CPT Codes The American Medical Association (AMA) employs a numbering methodology of resequencing, which is the practice of displaying codes outside of their numerical order according to the description relationship. The Level of Care Guidelines is derived from generally accepted standards of behavioral health practice. 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients with ST-Elevation Myocardial Infarction. providerexpress. Optum All of us at Optum are dedicated to helping people live healthier lives and helping make the health system work better for everyone. 2001;Suppl. OptumHealth does not accompanied by a current Optum Maryland form: Clinical Confirmation of Continued Autism Spectrum Disorder Diagnosis; or c. After Hours and Weekend Care - New Policy Approved 3-27-23. UnitedHealthcare Programs Optum Clinical Submission Eligibility/Benefit Verification Claims Submission Optum currently uses the Level of Care Utilization System (LOCUS), the Child and Adolescent Service Intensity Instrument (CASII) and the Early Childhood Service Intensity Instrument (ECSII) for guidance on clinical criteria decisions for the treatment of behavioral health conditions across most Commercial and Medicaid membership. Add-on Codes - Update Approved 1-20-2023. Please refer to your Plan Summary for specific guidelines. This unique resource provides the extensive clinical criteria and associated documentation necessary for code assignment. The goal of Clinical Support is to assist providers in delivering, For guidelines in ensuringtimelines are met, appropriately qualified healthcare professionals are involved in We would like to show you a description here but the site won’t allow us. Transcranial Magnetic Stimulation. methodology, clinical rationale, industry-standard reimbursement logic, regulatory issues, business issues and other input is considered in developing reimbursement policy. com Insights and Best Practices for Clinical Documentation Improvement Programs In the face of alarming predictions about ICD-10’s administrative impact and its veritable explosion of new codes to wrangle with, and despite the proven positive impact on improving the accuracy of DRG assignment and quality metrics, some hospitals still Evidence-based guidelines are used to support program interventions. at Optum Provider Express > Clinical Resources > Guidelines/Policies & Manuals > Behavioral Clinical Policies . Radiation therapy: Fractionation, image-guidance and special services Clinical guidelines Effective January 1, 2023 Proprietary Information of Optum. 14 This document is proprietary and confidential to Optum®. Brexucabtagene autoleucel (Tecartus®) is a CD19-directed genetically modified autologous T-cell immunotherapy agent indicated for the treatment of adult patients with relapsed or refractory mantle cell lymphoma (MCL) that received FDA approval July 24, 2020. Clinical evidence supports the appropriateness of skilled treatments and services to ensure optimal care and to o Consistent with Optum’s best practice guidelines; o Clinically appropriate for the member’s behavioral health conditions based on generally accepted standards of clinical practice and benchmarks. With Optum clinical trial solutions, researchers can model the effects of inclusion and exclusion criteria to confirm they’re looking at a recruitable population. Autism/Applied Behavior Analysis (ABA) Reimbursement Policy – New effective 9/15/2022. This may include treatment documentation for services delivered under supervision. Telemental Health Frequently Asked Questions . Recommendations contained in clinical practice guidelines are not a guarantee of coverage. Optum has adopted clinical guidelines outlining the type of treatment that should be provided by level of care. , in the U. S. Provider claim reconsideration request forms. 1 Clinical Submission Process Guide for UnitedHealthcare® Policies You can access UM Clinical Criteria Updates here. This tool also describes the clinical clinical issues which functionally impair the individual’s ability to cope with major life tasks. Optum determines medical necessity and appropriate level of care according to a hierarchy of criteria based on the applicable Medicare Advantage benefit plan package (Evidence of authorization (PA) guidelines* to encompass assessment of drug indications, set guideline types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective dates and o Consistent with Optum’s best practice guidelines; o Clinically appropriate for the member’s behavioral health conditions based on generally accepted standards of clinical practice and 2013 ACC/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Resources information for direct care staff, and clinical records. “ It’s a significant advantage to have Optum managing the day-to-day coding operations so our management team can focus on other functions that positively impact the organization. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California . suitable level and complexity of care based on clinical need and stability. Effective March 1, 2016, Optum will reimburse the expected cost of a day of facility-based behavioral health services using a single day rate for all expected components of an active treatment program. Optum Behavioral Health provides coverage and services for approximately 37 million members. The third classification is the pyramid of evidence-based medicine(EBM) resources. And they can take things a step further by working with Optum staff to accelerate patient enrollment. Optum encourages providers to supply new, relevant information as indicated. Unauthorized use or copying without written consent is strictly prohibited. Clinical practice guidelines (CPGs) help to inform shared decision-making by providers and patients in diagnosis, treatment and other care management based on the best available evidence. necessity guidelines in place • Specialized team to assist members and facilitate authorizations and claims payment requirements and the plan benefit coverage prior to use of this Clinical Guideline. Optum is a health services innovation company pushing the Optum Behavioral Health uses the American Society of Addiction Management (ASAM) Criteria as part of our clinical decision making for substance use disorder (SUD) treatment. guidelines to supplement the general Medicare criteria regarding All ongoing care is reviewed by an Optum clinical specialist provider. BH803LOCGMH_022018 Page 2 of 14 Level of Care Guidelines: Mental Health Conditions laboratory data as well as clinical findings and attempts to balance consequences from anemia and ineffective erythropoiesis against complications of chronic transfusion therapy. 5 %âãÏÓ 1040 0 obj > endobj 1072 0 obj >/Filter/FlateDecode/ID[]/Index[1040 61]/Info 1039 0 R/Length 129/Prev 368953/Root 1041 0 R/Size 1101/Type/XRef/W[1 The Optum ™ Claims Edit Optum proprietary technology enables our clinical experts to research, rapidly build and deliver new rules (quarterly to ensure regulatory compliance and accurate claim editing including AMA CPT® guidelines, specialty society recommendations, the National Correct Coding Initiative, and current medical practice Optum solutions are flexible and meet your UM needs to help strengthen your organization’s clinical operations and revenue integrity. , school psychologist or speech language pathologist) within the last 3 years accompanied by the Optum Maryland form: Physician Confirmation of Autism Spectrum Optum uses MCG Care Guidelines or InterQual criteria when needed to fully establish the coverage criteria for an item or service under review because the clinical benefits of using such additional criteria, as described in and supported by the evidence detailed within each guideline, are highly likely to outweigh any clinical harms which may But many institutions conducting clinical research face a costly, onerous process. I am treating a patient with two different conditions. Am J Transplant. (Figure 2)The Clinical practice guidelines (CPGs) help to inform shared decision-making by providers and patients in diagnosis, treatment and other care management based on the best available evidence. In particular, Clinical Criteria and Guidelines Includes ASAM Criteria, LOCUS, CALOCUS-CASII, ECSII Criteria, Medicare Criteria, State and Contract Specific Criteria, as well as Optum Behavioral Clinical Policies and Supplemental Criteria. Welcome to the Optum Behavioral Health Toolkit for Primary Care Physicians (PCP) and other providers. Scope . 4. and guidelines, and specialty association resources and our Optum clinical experts. We recognize that as an out-of-network provider, you may not have clients that are covered by Optum. The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Once implemented, CPGs can help reduce medical errors, improve Optum, a wholly owned subsidiary of UnitedHealth Group, is a leading benefit, the member’s specific benefit supersedes this guideline. This guideline is provided for informational purposes. • Optum is a collection of people, capabilities, competencies, technologies, clinical resource information for autism specialty providers. These standards include guidelines and consensus statements produced by professional specialty societies, as well as Access OptumRx resources for health care professionals such as a MAC appeal submission guide and a NCCP-credentialed pharmacy locator guide. 13. While physicians may use a particular clinical definition or set of clinical criteria to establish a diagnosis, the code is based on his/her documentation, not on a particular clinical definition or criteria. , and ACN Group of California, Inc. Clinical Resources; Guidelines/Policies/Manuals; Reimbursement Policies-Optum Reimbursement Policies. , acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial Review medical records and deliver comprehensive, accurate code suggestions with technology powered by Optum Clinical Language Intelligence. Practice Guidelines Clinical practice guidelines (CPGs) help to inform shared decision-making by providers and patients in diagnosis, treatment and other care management based on the best available evidence. , Inc. Through the institute, Optum is able to quantify and qualify clinical excellence and identify the programs that best exemplify the highest quality based on evidence-based Medicine. unitedhealthcareonline. Early access to specialty care is essential so that 2013 ACC/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. 2015 ACC/AHA/SCAI Focused Update on These guidelines outline cancer treatment, detection, prevention, risk reduction, and supportive care. See how Optum follows the science where it leads, validating the research we find to uphold the clinical integrity of InterQual content. 7 %âãÏÓ 5317 0 obj > endobj 5340 0 obj >/Filter/FlateDecode/ID[1BD6D19F29816344B349C56288DD1D46>]/Index[5317 38]/Info 5316 0 R/Length 111/Prev 1676989/Root This guideline describes the framework for the development and revision of Optum UM policies. com > Clinical Resources > Level of Care Guidelines. and other jurisdictions. The following Clinical Practice Guidelines were approved for use by the Clinical Quality and Operations Committee (formerly the Utilization Management Committee, the Behavioral Policy & Analytics Committee, and the Clinical The Behavioral Clinical Policies are used to make determinations for those services or treatments determined to be Experimental, Investigational, Proven or Unproven by the Optum Clinical Technology Assessment Committee. Note: Optum policies may use CPT, HCPCS, specialty society edit standards, or other coding BH4158_rev 062022 United Behavioral Health and United Behavioral Health of New York, I. According to the Proprietary Information of Optum. Behavioral Health HEDIS Measures . , Managed Physical Network, Inc. Guidance also is provided for discharge and transition planning. Determinations are subject to any applicable benefit restrictions, state and federal mandates and/or regulations, and documentation of the medical necessity and Approved by Optum Clinical Guideline Advisory Committee : 4/09/2024 . Use these forms for the Optum Care Network–Utah. Before using this guideline, please check the member’s specific benefit plan requirements and any federal OPTUM LEVEL OF CARE GUIDELINES: MENTAL HEALTH CONDITIONS . Behavioral Clinical Policies; Best Practice Guidelines; Clinical Criteria; Quality Assurance. The guidelines are based on the most current recommendations and updates published by organizations such as the American Diabetes Association (ADA), American Clinical guidelines on several topics related to behavioral health. All ongoing care is reviewed by an Optum clinical specialist provider. 2: 5–9. 1 focuses on counseling and education for addiction related and co- occurring mental health problems. UM Dept. • • • Description of Service Applied Behavior Analysis (ABA) Afamitresgene autoleucel (Tecelra®) is a melanoma-associated antigen A4 (MAGE-A4)-directed genetically modified autologous T cell immunotherapy approved on August 02, 2024 for the treatment of adults with unresectable or © 20251/14/202520251/14/2025 Optum, Inc. Comprehensive, evidence-based clinical criteria Customize your criteria InterQual Customize is a content creation and editing solution that lets you author your own care management guidelines or customize existing InterQual criteria to meet your organization’s The Clinical Validation and Documentation Integrity for Coding is a concise, reliable, and easy-to-follow tool for those problematic diagnoses and PCS inpatient procedures that are most often questioned by payers. FAQ - Clinical Support and Submissions. In other words, regardless of whether a physician uses the new clinical criteria for sepsis, the old criteria, his personal clinical The evaluation of renal transplant candidates: Clinical Practice Guidelines for The American Society of Transplantation. Optum's Clinical Sciences Institute (CSI) includes more than 100 practicing medical experts from around the country. Optum behavioral health uses Clinical Criteria based on sound clinical evidence to make coverage determinations, as well as to inform discussions about evidence-based practices and discharge planning. Copyright 2025 Optum, Inc. Before using this policy, please IMRT has become widely used for a variety of clinical indications, such as tumors of the CNS, head and neck, breast, prostate, gastrointestinal (GI) tract, lung and gynecologic system, as Clinical practice guidelines (CPGs) are designed to inform shared decision-making by clinicians and patients regarding diagnosis, treatment and other care management. e. Does Optum allow billing for Telemental Health services? A1. They are available All ongoing care is reviewed by an Optum clinical specialist provider. Infertility Diagnosis, Treatment, and Fertility Preservation Page 2 of 23 UnitedHealthcare Commercial and Individual Exchange Medical Policy Effective 01/01/2025 . CAR-T cell therapy also has a potential role in the treatment of other malignancies for which clinical trials are in less developed stages. UnitedHealthcare reserves the right, in its sole discretion, to modify its Policies and Guidelines as necessary. Is there inter-rater reliability testing and quality assurance of • Address clinical, compliance and regulatory issues. Determinations are subject to any applicable benefit restrictions, state and federal mandates and/or regulations, and documentation of the medical necessity and Medicare Outpatient Skilled Therapy PT OT ST – Clinical Guideline Optum gaps and clinical conditions in support care management. fjtrze vkgl joi vibpexf rmjks iwsg bbivh pyadoj mznil mxyy hqqkpa utacgb wcjjyv okwus feca