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LEVEL OF CARE ASSESSMENT TOOL (LOCAT) UTILIZATION REVIEW AND BENEFIT DETERMINATION CRITERIA COMPARISON UPDATED AUGUST 2014 Table of Contents Introduction LOCAT CRITERIA and Application to Level of Care What is LOCAT?...page 3 Admissions Criteria…pages 18-19 When was LOCAT developed?...page 4 Continued Stay Criteria…page 19 Who developed the LOCAT?...page 5 Discharge Criteria…page 19-20 What is Aetna’s approach to mental illness?...pages 5-6 Inpatient Levels of Care…pages 20-21 What does medically necessary mean?...page 7 Residential Levels of Care…pages 21-22 What is not medically necessary?...page 8 Partial Hospitalization Levels of Care…pages 23 and 24 How does Aetna determine which therapies to cover?..page 8-9 Intensive Outpatient Levels of Care…pages 24 and 25 Where can treatment occur?...pages 9-10 Outpatient Levels of Care…pages 26 and 27 Which facilities are covered by Aetna plans?...pages 10-11 How does LOCAT compare to other criteria?...page 27 What does Aetna expect from facilities?...pages 11-12 The Aetna Level Of Care Assessment Tool (LOCAT) pages 28-49 How is LOCAT used?...pages 12 For which conditions is the LOCAT used?...pages 13-17 What timeframe is considered?...page 17 What components are considered?...page 17 2 INTRODUCTION: The Level of Care Assessment Tool (LOCAT) is a clinical behavioral health patient management instrument developed by Aetna. The LOCAT is an instrument used to guide and track level of care decisions for Aetna members in need of behavioral health services. The LOCAT also serves to improve and standardize data collection and documentation for the behavioral health provider network. What is LOCAT? The Aetna Level of Care Assessment Tool or "LOCAT" is a clinically-based scoring system created to aid Aetna in the decision- making process. The LOCAT helps Aetna determine the appropriate level of care for effective treatment. LOCAT was developed to provide guidelines for evaluating the medical necessity of care for mental health disorders. In treating behavioral health symptoms and diagnosis, LOCAT is used to help determine: the appropriate levels of care the type of care required for patients - from routine outpatient services to specialized inpatient treatment the medical necessity of all the various treatment options LOCAT is to be used as a guideline to help evaluate a patient’s symptoms. The tool helps Aetna by identifying and scoring various behavioral health dimensions, and by narrowing down some of those dimensions into sub-dimensions. This analysis creates a more complete clinical picture of the patient. 3 When was LOCAT developed? The first version of the LOCAT was developed in 1991. The tool was designed to guide care for mental health treatment much in the same way that the American Society of Addiction Medicine (ASAM) criteria provides care guidelines for chemical dependency. This Level of care Assessment Tool (LOCAT) was developed to provide guidelines for evaluating the medical necessity of care for mental health disorders. The intent of the LOCAT tool is not to guide care for substance related and addictive disorders but may be used in conjunction with such guidelines when the patient has been diagnosed with both a Mental Health and Addictive Disorder. These guidelines are not a replacement for good clinical judgment but do provide a foundation for reviewing medical necessity. In addition, the benefits available to a covered person are based on the purchased Plan of Benefits. The LOCAT developers believed that it is crucial to see the patient as a whole person, with various psychological and social influences, and not just a diagnosis. To that end, the levels of care decision making is not primarily diagnosis driven, but instead takes into account how the individual functions in various settings/situations. 4 Who developed LOCAT? Aetna staff believed that bringing in outside experts could benefit the development of a tool to assist with determining medical necessity. To that end, a Blue Ribbon Panel of outside expert psychiatrists were selected to direct the project from 1990-1991. They utilized accepted community standards of care to determine which data should be considered when a patient is in need of mental health services. LOCAT 1.0 was developed on this basis. This first version of the tool was put into daily patient management operations for approximately two and a half years.