Point32 Commercial Clinical Policy

Point32 Behavioral Health Inpatient and 24 Hour Level of Care Determinations(Eff. beginning 1.1.24) Form

Effective Date

01/01/2024

Last Reviewed

10/18/2023

Original Document

  Reference



For Harvard Pilgrim Health Care Members:

Members may access materials by logging into their online account (visit www.harvardpilgrim.org, click on Member Login, then Plan Details, Prior Authorization for Care, and the link to clinical criteria) or by calling Member Services at 888-333-4742

For Tufts Health Plan Members:

Tufts Health Plan Commercial Plan products:

If you are a registered Tufts Health Plan provider click here to access the Provider Website. If you are not a Tufts Health Plan provider, please click on the Provider Log-in and follow instructions to register on the Provider website or call Provider Services at 888-884-2404

Tufts Health Public Plans products:

InterQual® SmartSheet(s) available as part of the prior authorization process

Tufts Health Plan requires the use of current InterQual® Smartsheet(s) to obtain prior authorization. In order to obtain prior authorization for procedure(s), choose the appropriate InterQual® SmartSheet(s) listed below. The completed SmartSheet(s) must be sent to the applicable fax number indicated above, according to Plan

Clinical Guideline Coverage Criteria

Behavioral Health Inpatient (inclusive of Mental Health and Substance Use Disorder) Levels of Care

The Plan uses InterQual®* and American Society of Addictive Medicine (ASAM)^ criteria for determining medical necessity for behavioral health levels of care. Please see below for specific details:

  1. The Plan uses InterQual criteria for determining continued stay post notification for:
    • Acute inpatient services
      • The Plan provides coverage for special resources or accommodations if Member's immediate care requires adjustments to a facility's usual staffing needs. For Massachusetts plans, The Plan will approve coverage in accordance with accepted practice and/or federal and state standards.
    • Acute residential services/24-hour diversionary services unless otherwise specified
    • All Substance Use Disorder (SUD)-specific inpatient levels of care unless otherwise specified. See below.
  2. The plan uses InterQual The ASAM Criteria Navigator for determining continued stay post notification for:
    • Level 4 Medically Managed Intensive Inpatient Services, Adult/Adolescent for the following lines of business:
      1. All Commercial plans
      2. Tufts Health Direct
      3. Tufts Health Together
      4. Tufts Health RITogether
      5. Tufts Health Unify (for non-alcohol Level 4 treatment)
      6. Tufts Health Senior Care Options (for non-alcohol Level 4 treatment)
    • Level 3.7 Medically Monitored Intensive Inpatient Services, Adult/Adolescent for the following lines of business:
      1. All Commercial Plans
      2. Tufts Health Direct
      3. Tufts Health Together
      4. Tufts Health RITogether
      5. Tufts Health Unify
      6. Tufts Health Senior Care Options
    • Level 3.5 Clinically Managed High-Intensity Residential Services, Adult/Adolescent for the following lines of business:
      1. All Commercial Plans
      2. Tufts Health Direct
      3. Tufts Health Together
      4. Tufts Health RITogether
      5. Tufts Health Unify
      6. Tufts Health Senior Care Options
    • Level 3.1 Clinically Managed Low-Intensity Residential Services, Adult/Adolescent for following lines of business:
      • Behavioral Health Inpatient and 24-Hour Level of Care Determinations
        1. Tufts Health Together
        2. Tufts Health RITogether
        3. Tufts Health Unify
        4. Tufts Health Senior Care Options

*InterQual Criteria are nationally recognized medical necessity behavioral health criteria developed by a clinical research staff, which includes physicians, registered nurses, and other healthcare professionals. The clinical content of the criteria is annually reviewed, updated, and validated by a national panel of clinicians and medical experts, including those in community and academic practice settings, as well as within the managed care industry throughout the United States.

InterQual, The ASAM Criteria Navigator is a clinical decision support tool consistent with The American Society of Addiction Medicine’s The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. ASAM Criteria are nationally recognized treatment criteria for addictive, substance-related and dual diagnosis conditions.