Cov Cai Kho Mob Yuav Tsum Tau

Carelon Behavioral Health of California's Medical Necessity Criteria (MNC), tseem hu ua cov txheej txheem kho mob, raug tshuaj xyuas thiab hloov kho yam tsawg kawg ib xyoos ib zaug kom ntseeg tau tias lawv muaj kev cuam tshuam txog qhov kev txhim kho tshiab tshaj plaws hauv kev pabcuam rau cov tib neeg nrog kev kuaj mob tus cwj pwm. Carelon Behavioral Health of California's Quality Management/Utilization Management/Case Management Committee (QMUMCM) txais, tshuaj xyuas, kho thiab pom zoo Cov Kev Cai Kho Mob rau ib tus neeg siv khoom thiab cov cai tswj hwm.

Cov Kev Xav Tau Kev Kho Mob yuav txawv raws li kev cog lus ntawm tus kheej, lub xeev/tsoomfwv cov cai thiab cov kev pab them nqi rau cov tswv cuab. Txhawm rau txiav txim siab txog yam xav tau kev kho mob kom raug, siv cov hauv qab no los ua ib qho kev qhia raws li hom phiaj xwm thiab hom kev pabcuam raug thov:

  1. Rau txhua tus tswvcuab Medicare, txheeb xyuas Lub Chaw Pabcuam rau Medicare thiab Medicaid (CMS) National Coverage Determinations (NCD) lossis Local Coverage Determinations (LCD) Criteria.
  2. Yog tias tsis muaj CMS cov txheej txheem rau cov tswv cuab Medicare, Hloov Kho Kev Khomob Interqual® Behavioral Health Criteria lossis MCG yuav tsim nyog.
    * Kev zam yog tias cov txheej txheem teeb tsa tsis pom hauv 1 lossis 2 saum toj no:
    • Txawm li cas los xij Carelon Behavioral Health ntawm California Cov Kev Xav Tau Kev Kho Mob los yog Elevance Clinical UM Cov Lus Qhia yuav tsim nyog siv.
  3. rau kev pabcuam kev coj cwj pwm, cov txheej txheem kev cai feem ntau yog xeev lossis phiaj xwm / daim ntawv cog lus tshwj xeeb: 
    • California Cov Kev Npaj Ua Lag Luam siv LOCUS, CALOCUS-CASII, lossis ECSII cov qauv.
      * Kev zam rau kev npaj ua lag luam vim tsis muaj cov txheej txheem tsis muaj txiaj ntsig tam sim no muaj:
      • InterQual® Behavioral Health Criteria lossis Elevance Clinical UM Guidelines yog siv rau Kev Kho Mob Cwj Pwm (BHT).
      • MCG tuaj yeem siv rau kev pabcuam Transcranial Magnetic Stimulation (TMS).
    • California Medi-Cal Plans siv:
      • Specialty Mental Health Services (SMHS): Title 9 California Code of Regulations
      • Non-Specialty Mental Health Services (NSMHS): Cov kev taw qhia tam sim no tshaj tawm los ntawm Lub Xeev Tsab Ntawv Npaj Txhua Yam.
        * Kev zam rau Medi-Cal cov phiaj xwm vim tias tsis muaj cov txheej txheem tsis muaj txiaj ntsig tam sim no muaj:
        • InterQual® Behavioral Health Criteria lossis Elevance Clinical UM Guidelines yog siv rau Kev Kho Mob Cwj Pwm (BHT).
  4. rau cov kev pab cuam txog kev siv tshuaj, Carelon Behavioral Health of California siv American Society of Addiction Medicine (ASAM) cov txheej txheem rau txhua txoj kev lag luam.
    * Kev zam rau kev ua tswv cuab Medicare:
    • InterQual® Behavioral Health Criteria (Substance Use Lab Testing) thiab NCD cov txheej txheem (Detoxification and/or Rehabilitation).

Cov Txheej Txheem Kev Kho Mob muaj nyob hauv online ntawm hyperlinks thaum twg los tau thiab muaj raws li qhov kev thov.

Cov hauv qab no yog cov txheej txheem teeb tsa Carelon Behavioral Health of California tuaj yeem siv los txiav txim siab Kev Kho Mob:

  1. Chaw rau Medicare thiab Medicaid (CMS) Cov Cai
    • Lub Medicare Coverage Database (MCD) muaj tag nrho Cov Kev Pabcuam Hauv Tebchaws (NCDs) thiab Kev Txiav Txim Hauv Lub Zos (LCDs).
    • Rau txhua tus tswvcuab Medicare, ua ntej txheeb xyuas qhov cuam tshuam txog NCD lossis LCD Cov Qauv.
  2. Kev Cai Lij Choj
    Cov Kev Cai Lij Choj yog kev sib koom tes- thiab lub xeev tshwj xeeb Kev Kho Mob Yam Tseem Ceeb.
    • Cov phiaj xwm kev lag luam hauv California siv LOCUS/CALOCUS- CASII/ECSII cov qauv thiab WPATH Standards of Care ua raws li SB 855. Cov ntaub ntawv ntxiv ntsig txog cov txheej txheem no tuaj yeem nrhiav tau hauv Cov Kev Pabcuam Kev Kawm hauv qab no.
  3. American Society of Addiction Medicine (ASAM) Cov Cai
    • American Society of Addiction Medicine (ASAM) Cov Txheej Txheem tsom mus rau kev siv tshuaj kho mob. 
      Copyright 2015 los ntawm American Society of Addiction Medicine. Reprinted nrog kev tso cai. Tsis muaj lwm tus neeg tuaj yeem luam daim ntawv no tag nrho lossis ib feem hauv ib hom ntawv lossis nruab nrab yam tsis muaj kev tso cai ua ntej ntawm ASAM.
    • Tshwj tsis yog Custom Criteria muaj los yog rau Kev Tshawb Fawb Siv Tshuaj (uas pom muaj nyob rau hauv InterQual® Behavioral Health Criteria), ASAM cov txheej txheem yog cov txheej txheem rau kev siv tshuaj kho mob.
    • Yog xav paub ntxiv txog ASAM Cov Cai, mus saib hauv Taw qhia rau ASAM Cov Cai rau Cov Neeg Mob thiab Tsev Neeg
  4. Hloov Kho Kev Noj Qab Haus Huv InterQual ® Cov Cwj Pwm Kev Noj Qab Haus Huv
    • Tshwj tsis yog tias muaj lwm yam kev cai teev tseg, Carelon Behavioral Health of California siv Change Healthcare's InterQual® Behavioral Health Medical Necessity Criteria.
  5. Carelon Behavioral Health ntawm California txoj cai kho mob uas tsim nyog

Cov ntaub ntawv kawm: Hauv qab no yog cov txuas mus rau cov peev txheej kev cob qhia tam sim no. Yog xav paub ntxiv, mus saib cov vev xaib no:

ASAM:

ECSII:

LOCUS/CALOCUS-CAS II:

24-teev nkag

Carelon Behavioral Health of California muab kev nkag mus rau 24-teev, suav nrog, tab sis tsis txwv rau, cov tsev kho mob tsis muaj ntawv cog lus, kom tau txais kev tso cai raws sij hawm rau kev kho mob uas tsim nyog, suav nrog cov kev pab cuam tom qab kev ruaj ntseg. Yog koj xav tau kev pab, nyem qhov no rau Carelon Behavioral Health of California tus xov tooj hu dawb.

TXOJ CAI TSHIAB

  1. Txhua qhov kev txiav txim siab UM thiab CM tsuas yog ua raws li qhov tsim nyog ntawm kev saib xyuas thiab kev pabcuam thiab muaj nyob ntawm qhov kev pabcuam. Qib ntawm Kev Kho Mob yog siv los ua cov txheej txheem.
  2. Tsis muaj kev txhawb nqa nyiaj txiag los txhawb kom ua raws li kev siv lub hom phiaj thiab cuam tshuam rau kev siv tsis raug. Kev txhawb nqa nyiaj txiag raws li tus naj npawb ntawm kev txiav txim siab tsis zoo lossis tsis lees txais kev them nyiaj los ntawm ib tus neeg koom nrog UM kev txiav txim siab raug txwv.
  3. Carelon Behavioral Health of California tsis txiav txim siab txog kev ntiav, nyiaj them poob haujlwm, raug rho tawm haujlwm, nce qib, lossis lwm yam teeb meem zoo sib xws nrog rau ib tus neeg raws li qhov muaj feem cuam tshuam uas tus neeg yuav txhawb nqa qhov tsis lees txais cov txiaj ntsig.
  4. Kev txwv tsis pub muaj kev txhawb nqa nyiaj txiag tsis siv rau kev txhawb nqa nyiaj txiag tsim los ntawm cov phiaj xwm kev noj qab haus huv thiab cov kws kho mob.
  5. Cov neeg ua haujlwm tswj hwm kev siv nyiaj tsis muaj txiaj ntsig lossis kev txhawb nqa, tsis yog nyiaj txiag lossis lwm yam, cov kws kho mob, cov neeg saib xyuas kev siv, cov saib xyuas kev kho mob, kws tshaj lij kws kho mob, lossis lwm tus neeg koom nrog hauv kev siv / kev tshuaj xyuas cov ntaub ntawv, rau kev tshaj tawm kev tsis lees paub lossis kev pabcuam, lossis txwv tsis tsim nyog los yog hloov kev saib xyuas suav nrog cov neeg ua haujlwm uas koom nrog kev cog lus / kev tswj hwm lub network uas tuaj yeem cuam tshuam rau kev xa mus rau cov kws kho mob tshwj xeeb / cov kev pabcuam.