Beacon 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 Beacon’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 Corporate Medical Management Committee (CMMC) adopts, reviews, revises and approves Medical Necessity Criteria per client and regulatory requirements.
Medical Necessity Criteria varies according to state and/or contractual requirements and member benefit coverage. To determine the proper Medical Necessity Criteria, use the following as a guide:
- For all Medicare members, first identify relevant Centers for Medicare and Medicaid (CMS) National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) Criteria.
- If no CMS criteria exists for Medicare members and for all non-Medicare members, identify relevant custom Medical Necessity Criteria.
- If no custom criteria exists for the applicable level of care and the treatment is substance use related, the American Society of Addiction Medicine (ASAM) criteria would be appropriate.
* Exception: Substance Use Lab Testing Criteria is in InterQual® Behavioral Health Criteria.
- If the level of care is not substance use related, Change Healthcare’s Interqual® Behavioral Health Criteria would be appropriate.
- If 1-4 above are not met, CHIPA’s Medical Necessity Criteria would be appropriate.
Historical criteria are provided for informational purposes only and are not subject to the same review process/timeframes. To see historic criteria, click here. Medical Necessity Criteria is available online via hyperlinks whenever possible and is available upon request.
The following are CHIPA’s Medical Necessity Criteria:
- Centers for Medicare and Medicaid (CMS) Criteria
- The Medicare Coverage Database (MCD) to contains all National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).
- For all Medicare members, first identify relevant NCD or LCD Criteria.
- Change Healthcare’s InterQual ® Behavioral Health Criteria
- Effective September 21, 2019, CHIPA will begin using Change Healthcare’s InterQual® Behavioral Health Medical Necessity Criteria, unless there is an otherwise noted Custom Criteria set.
- American Society of Addiction Medicine (ASAM) Criteria
- The American Society of Addiction Medicine (ASAM) Criteria focuses on substance use treatment.
- For information about The ASAM Criteria, see the Introduction to The ASAM Criteria for Patients and Families 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.
- Custom Criteria
- Alameda Alliance for Health Commercial: LOCUS/CALOCUS/ECSII
- Anthem Blue Cross Commercial: LOCUS/CALOCUS/ECSII
- Central California Alliance for Health Commercial: LOCUS/CALOCUS/ECSII
- LA Care Commercial: LOCUS/CALOCUS/ECSII
- Orange County Mental Health Medicaid – Specialty Mental Health Services
If you need assistance identifying the correct criteria, contact CHIPA.
Health Plan Specific Guidelines and Resources
- All UM decision making are based only on appropriateness of care and services, existence of coverage, and member’s healthcare is not compromised at any time. CHIPA’s and or Health Plan’s Level of Care Criteria is used as a guideline.
- CHIPA does not reward practitioners or other individuals for issuing denials of coverage or services. Financial incentives based on the number of adverse determination or denials of payment made by any individual involved in UM decision making is prohibited.
- Financial incentives for UM decision makers do not encourage decisions that result in underutilization.
- Utilization Management staff is not financially rewarded nor receives incentives to influence the referral process and practitioners are ensured independence and impartiality in making referral decisions that will not influence: hiring, compensation, termination, promotion or any other similar matters.
OUR MISSION AND VALUES
Mission: We help people live their lives to the fullest potential
We speak honestly and act ethically. Our character guides our daily work. We gain the confidence of others by doing the right thing.
We believe in others and see their potential. With the right support, all individuals can achieve their goals.
We build great teams by leveraging individual strengths. We share, partner and collaborate with others in the name of mutual goals.
We embrace that our work is hard, and sometimes does not go as planned. We meet these challenges head on and constantly strive to better ourselves and our services.
We are learners, innovators and original thinkers. We use our experience, imagination and wisdom to deliver tangible, positive outcomes.
We start the conversations that matter. We advance the dialogue on important issues and affect change for the better. If not us, then who?