Providers

Carelon Behavioral Health and CHIPA share similar visions – to improve the health and well-being of individuals coping with mental health and substance use conditions. We make this vision a reality through recovery-focused programs and effective partnerships with you, our network providers.

Our mission and values guide the way we treat our providers, members and each other. They are at the heart of all we do.

A better quality of life for patients starts with you, the providers at the core of their health care delivery. Our streamlined care and reporting solutions save you time and energy so you can put the focus back on your patients.

Click here to access clinical information, forms and to locate in-network providers.

Join Our Provider Network

All of Carelon Behavioral Health’s and CHIPA’s providers are licensed in the state of California to provide behavioral health services, and include psychiatrists, psychologists, clinical social workers, marriage and family therapists, and registered nurse practitioners. If you are a licensed behavioral health professional and are interested in joining our provider network, please contact Provider Relations at 800-397-1630, then follow the prompts to the appropriate department.

Clinical Practice Guidelines

CHIPA’s clinical practice guidelines help ensure quality care for our members. We adopt clinical practice guidelines from national organizations and/or in cooperation with specialty organizations and collaborative groups. We review these clinical practice guidelines annually to include new information that reflects best practices.  Click here to access the guidelines.

Medical Necessity Criteria

CHIPA’s Medical Necessity Criteria (MNC), also known as clinical criteria, are reviewed and updated at least annually to ensure that they reflect the latest developments in serving individuals with behavioral health diagnoses. CHIPA’s Executive Committee adopts, reviews, revises and approves Medical Necessity Criteria per client and regulatory requirements.

Medical Necessity Criteria may vary according to individual contractual obligations, state/ federal requirements and member benefit coverage. To determine the proper Medical Necessity Criteria, use the following as a guide based on plan type and type of service being requested:

1. For all Medicare members, identify relevant Centers for Medicare and Medicaid (CMS) National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) Criteria.
2. If no CMS criteria exists for Medicare members, Change Healthcare’s Interqual® Behavioral Health Criteria or MCG would be appropriate.
   * Exception if criteria sets not found in 1 or 2 above:
   1. CHIPA’s Medical Necessity Criteria may be appropriate to use.
3. For behavioral health services, custom criteria is often state or plan/contract specific:
   1. California Commercial Plans utilize LOCUS,CALOCUS-CASII, or ECSII criteria.
      * Exception for Commercial plans due to there being no non-profit criteria currently available:
      1. InterQual® Behavioral Health Criteria is utilized for Behavioral Health Treatment (BHT) services.
   2. California Medi-Cal Plans utilize:
      Specialty Mental Health Services (SMHS): Title 9 California Code of Regulations
      Non-Specialty Mental Health Services (NSMHS): The most current guidance provided by the state’s All Plan Letter.
      * Exception for Medicare membership:
      1. InterQual® Behavioral Health Criteria is utilized for Behavioral Health Treatment (BHT) services.
4. For substance use related services, CHIPA uses the American Society of Addiction Medicine (ASAM) criteria for all lines of business.
   * Exception for Medicare membership:
   1. InterQual® Behavioral Health Criteria (Substance Use Lab Testing).

Medical Necessity Criteria are available online via hyperlinks whenever possible and are available upon request.

The following are criteria sets CHIPA may utilize to make Medical Necessity determinations:

1. 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.
2. Custom Criteria
   • The Custom Criteria are network and/or state specific Medical Necessity Criteria.
   • California Commercial plans utilize LOCUS/CALOCUS-CASII/ECSII criteria in compliance with SB 855. Additional information related to these criteria can be found in the Educational Resource section below.
     • LOCUS/CALOCUS-CASII
     • ECSII
   • County contracts utilize Title 9 California Code of Regulations.
     • California Medi-Cal for Psychiatric Inpatient Hospital Services and Psychiatric Health Facility Services- State (MH- IP) [1820.205]
     • Title 9 California Code of Regulations Chapter 11 Medi-cal Specialty Mental Health Services
     • Title 9 California Code of Regulations Chapter 11 Medi-cal Non-Specialty Mental Health Services
3. American Society of Addiction Medicine (ASAM) Criteria
   • The American Society of Addiction Medicine (ASAM) Criteria focuses on substance use treatment.
     * 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 exists or for Substance Use Lab Testing (which is found in in InterQual® Behavioral Health Criteria), ASAM criteria is the criteria for substance use treatment services.
   • For information about The ASAM Criteria, see the Introduction to The ASAM Criteria for Patients and Families
4. Change Healthcare’s InterQual ® Behavioral Health Criteria
   • Unless there is an otherwise noted Custom Criteria set, CHIPA uses Change Healthcare’s InterQual® Behavioral Health Medical Necessity Criteria.
5. CHIPA’s proprietary Medical Necessity Criteria

Educational Resources: Below are links to current training resources.  For more information, visit these websites:

ASAM:

• ASAM Training Dates

ECSII:

• AACP Training Dates

LOCUS/CALOCUS-CASII:

• Deerfield Training Dates
• Patient and Family Guide
• Members and Providers can access the full LOCUS/CALOCUS-CASII criteria using the following LOGIN information:
  User Name: Beacon3
  Password: BeaconLOCUS3

24-Hour Access:

CHIPA provides 24-hour access, including, but not limited to, non-contracting hospitals, to obtain timely authorization for medically necessary care, including post-stabilization services. If you need assistance, click here for CHIPA’s toll-free contact information.

Health Plan Specific Guidelines and Resources

• Anthem Blue Cross
• Provider Manual
• EDI Information

AFFIRMATIVE STATEMENT

1. All UM and CM decision making are based only on appropriateness of care and services and existence of coverage. Level of Care Criteria are used as a guideline.
2. There are no financial incentives to encourage adherence to utilization targets and discourage under-utilization. Financial incentives based on the number of adverse determination or denials of payment made by any individual involved in UM decision making are prohibited.
3. CHIPA does not make decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual based upon the likelihood that the individual will support the denial of benefits.
4. The prohibition of financial incentives does not apply to financial incentives established between health plans and health plan providers.
5. Utilization Management staff in no way rewards or incentivizes, either financially or otherwise, practitioners, utilization reviewers, clinical care managers, physician advisers, or other individuals involved in conducting utilization/case management review, for issuing denials of coverage or service, or inappropriately restricting or diverting care including staff that engage in contracting/network management activities that could potentially influence referrals to specific providers/services.

OUR MISSION AND VALUES

Mission: We help people live their lives to the fullest potential

Corporate Values: