Level of Care Criteria for Addiction Treatment Centers
Determining Level of Care
Have you checked with insurance companies lately to determine which criteria they are using to determine level of care? If not, now is a good time to do so. Checking-in with insurance companies and the state for level of care criteria will can help you avoid authorization issues and claim denials. It will also help you write and win appeals when discrepancies arise.
Most facilities and clinicians use the American Society of Addiction's (ASAM) criteria to determine a patient's level of care. Developed in the 1980's, ASAM is a national set of criteria used to provide outpatient oriented and results based care for people suffering from addiction. It is the most widely used and comprehensive guideline for placement, continued stay, and transfer of patients with addiction and co-occurring conditions. ASAM criteria are required in over 30 states and have been an indispensable tool that addiction medicine professionals rely on to provide terminology for describing the spectrum of addiction services.
ASAM isn't the only criteria used to determine a patient's level of care, though. While it is used by most facilities and insurers, we recently found that the state of California is using another set of guidelines - LOCUS.
What is LOCUS criteria?
The level of care utilization system (LOCUS) works similarly to ASAM and was designed to
determine what level of care is required for mental health and/or substance abuse patients. With LOCUS, the clinician rates the patient in each category. The cumulative score indicates what level of care the client should receive. This process is similar to ASAM but guidelines are different enough to potentially cause problems.
It's possible for a facility to determine a patient's level of care using ASAM and proceed accordingly, only to have an insurer come to a different conclusion using LOCUS. In these cases, authorization for treatment may be denied because the two case managers have reached a different understanding of the patient's needs, simply by utilizing a different method of determining them.
In a recent state appeal (overturned in our favor), our utilization review manager noticed that the state used LOCUS criteria rather than ASAM guidelines. We haven’t experienced case managers referencing LOCUS before, however, because the state is using it to conduct independent medical reviews (IMR), we recommend that substance abuse and mental health facilities be familiar with both.
Train Your Staff
You facility’s financial health could be affected if you do not prepare for these types of changes in regulation. You should consider adding LOCUS guidelines to your charts and educating your staff on both ASAM and LOCUS level of care scoring criteria. You may also want your clinicians to do brief assessments periodically throughout the clients stay. It will help justify the level of care you are providing and and could also help during the utilization review process.