Centers for Medicare and Medicaid (CMS) Criteria
The Medicare Coverage Database (MCD) contains all national coverage determinations (NCDs) and local coverage determinations (LCDs).
For all Medicare members, first identify relevant NCD or LCD Criteria.
Change Healthcare InterQual® Behavioral Health Criteria
Carelon Behavioral Health utilizes Change Healthcare’s InterQual Behavioral Health Medical Necessity Criteria for mental health levels of care and substance use laboratory testing, unless otherwise noted that custom criteria should be used.
American Society of Addiction Medicine (ASAM) Criteria
The American Society of Addiction Medicine (ASAM) criteria focuses on substance use treatment.
For information about The ASAM Criteria, see 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.)
Unless custom criteria exist (for example, LOCADTR in New York) or for substance use laboratory testing (found in InterQual Behavioral Health Criteria), ASAM criteria are used for substance use treatment services.