1. (a) Utilization review coverage determinations concerning service type, intensity, level of care placement, continued stay, and transfer or discharge, including any reassessments or redeterminations, that are within the scope of the following instruments shall be made by using the most current version of the instrument designated by the respective nonprofit professional association, exclusive of all other clinical criteria, decision making tools, or applications:

   1. (1) For a primary substance use disorder diagnosis in adolescents and adults, “The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions” by the American Society of Addiction Medicine.
   2. (2) For a primary mental health diagnosis in adults nineteen (19) years of age and older, “Level of Care Utilization System” (LOCUS) by the American Association for Community Psychiatry.
   3. (3) For a primary mental health diagnosis in children six (6) to eighteen (18) years of age, “Child and Adolescent Level of Care/Service Intensity Utilization System” (merged CALOCUS-CASII) by the American Association for Community Psychiatry and the American Academy of Child and Adolescent Psychiatry, or “Child and Adolescent Service Intensity Instrument” (CASII) by the American Academy of Child and Adolescent Psychiatry.
   4. (4) For a primary mental health diagnosis in children five (5) years of age and younger, “Early Child Service Intensity Instrument” (ECSII) by the American Academy of Child and Adolescent Psychiatry.

2. (b) In using the instruments required by subdivision (a) of this section, an insurer shall prioritize safety and efficacy when applying clinical judgment in utilization review. If ambiguity or uncertainty exists regarding whether:

   1. (1) An insured has met criteria for a score within one or more of the evaluation parameters of the LOCUS, CALOCUS-CASII, or ECSII instrument, which could be due to inadequate or conflicting information or difficulty in making a judgment about whether the available information is consistent with any of the criteria for a score, then an insurer shall assign the highest score in which it is more likely than not that at least one criterion has been met.
   2. (2) An insured has met the dimensional admission criteria of The ASAM Criteria, then an insurer shall authorize a more intensive level of care if it is uncertain that the insured can be safely managed in a less intensive level of care.
3. (c) A determination made by the instrument shall be binding on an insurer. An insurer shall cover the level of care or service intensity determined by the instrument and shall not reduce the amount, duration, or scope of benefits or otherwise modify the determination made by the instrument, or require, request, or incentivize an insured to obtain services at a lower level of care or service intensity than that determined by the instrument. If a lower level of care or service intensity is requested by an insured without having been required, requested, or incentivized by the insurer to make such request, then an insurer shall cover the level of care or service intensity the insured requested. This subdivision does not prevent an insurer from covering a higher level of care or service intensity than that determined by an instrument, such as when clinically appropriate or legally mandated.
4. (d) An insurer shall continuously maintain in good standing a licensing agreement, when required by the nonprofit professional association, to use each instrument required by subdivision (a) of this section. An insurer shall access and use the instrument and scoring algorithm as designated by the respective nonprofit professional association, regardless of whether the instrument is offered directly by the association, or by a third party through an arrangement with the association.

Note: Authority cited: Sections 10144.5, 10144.52 and 10144.57, Insurance Code. Reference: Sections 10123.135, 10144.4, 10144.5, 10144.51, 10144.52, 10144.53 and 10144.57, Insurance Code.

History

1. New section filed 6-26-2025; operative 6-26-2025 pursuant to Government Code section 11343.4(b)(3) (Register 2025, No. 26).