LOCUS and CALOCUS denials: how to answer a mental-health level-of-care score

What does a LOCUS or CALOCUS-CASII denial look like?

The notice says the reviewer’s ratings point to a lower level than the one requested. It may give a composite score, a recommended level such as “Level 3,” or a single dimension, for example that risk of harm no longer requires daily programming. Often it names the instrument but not the ratings, the version or the records rated.

LOCUS and CALOCUS-CASII rate six dimensions on a five-point scale and add them into a composite; the publisher’s decision method turns the profile into a recommended level, and a single very high rating, such as risk of harm, can set the level on its own. Both publishers call the result a recommendation that does not replace clinical judgment.

LOCUS has seven levels, from Level 0 basic services to Level 6, traditionally hospital care. Its publisher gives intensive outpatient as a Level 3 example and partial hospitalization as Level 4; Level 5 is residential. CALOCUS-CASII also places partial hospitalization in Level Four. A denial that “supports Level 3” for a PHP request is a one-level dispute, so the appeal has to move enough ratings to close it.

Which LOCUS-family instrument fits the patient’s age?

LOCUS is for adults, CALOCUS-CASII for children and adolescents ages 6 to 18, and ECSII for children from birth to 5. The American Association for Community Psychiatry (AACP) publishes LOCUS, developed CALOCUS-CASII jointly with the American Academy of Child and Adolescent Psychiatry (AACAP), and AACAP developed ECSII. Check that the reviewer used the right one.

The age ranges meet at 18, so ask which tool the reviewer used before you compare ratings. CALOCUS-CASII is a merged instrument: Optum replaced CASII with it on November 13, 2021, so older notes and payer letters may still cite CASII alone.

Which payers and state laws point reviewers to LOCUS or CALOCUS-CASII?

It depends on the payer and the state. Optum says it uses LOCUS, CALOCUS-CASII and ECSII for mental health across most commercial and Medicaid membership unless state, federal, contract or customer requirements apply. California requires the health care service plans it regulates to apply the most recent criteria developed by the nonprofit professional association for the relevant specialty.

California’s Health and Safety Code section 1374.721 also bars those plans from applying different, additional, conflicting or more restrictive criteria to level-of-care decisions within that scope, and requires them to give providers and enrollees the criteria and training materials at no cost. It names no instruments and excludes Medi-Cal managed care contracts. If a California plan cites LOCUS or CALOCUS-CASII, ask which version it treats as most recent.

The ASAM criteria guide covers the parallel rules for substance use care, the level-of-care guide compares the criteria four large behavioral-health payers publish, and the Optum payer guide covers Optum’s appeal steps.

How do you get the reviewer’s dimension ratings and instrument version?

Ask in writing, the day the denial arrives, for the rating in each dimension, the composite score, the recommended level, the instrument name and version, the assessment date and the records the reviewer rated from. Also ask who completed the rating and whether they are trained on the instrument. Employer plans must disclose criteria and relevant documents.

1. 01Note the instrument and version the notice cites, or that it named none. The LOCUS adult instrument says actual assessments must be performed with the LOCUS software, so ask what produced the recommendation.
2. 02Ask for each dimension rating, the composite and any rule that set the level on its own.
3. 03Ask which notes and dates the reviewer rated from, so stale records show up.
4. 04For employer plans, cite 29 CFR 2560.503-1(g)(1)(v)(A) (the guideline relied on, or a statement that a copy is free on request) and (h)(2)(iii) with (m)(8) (free copies of documents relevant to the claim, including those generated in deciding it).
5. 05Cite 29 CFR 2590.712(d)(1): mental health medical-necessity criteria must be made available on request to participants, beneficiaries and contracting providers. The criteria request letter tool drafts the request.

How do you compare the reviewer’s ratings with the program’s own assessment?

Put the two rating sets side by side, dimension by dimension, with the date and source of each, and compare only assessments that cover the same period. Where the program rated higher, cite the dated record fact behind that rating. Where the ratings match, move on and spend the appeal on the dimensions that change the level.

The LOCUS instructions ask raters to score the current clinical picture and to use history only where a dimension’s criteria call for it. They also say that when the evidence is ambiguous, the rater should generally choose the highest rating that is more likely than not met, erring toward caution. Both points matter when a reviewer rated from a sparse or early note.

Your own rating carries weight only if a trained clinician completed it near the review date and the notes support it, so re-rate at each concurrent review. The level-of-care crosswalk builder lays each dimension next to your evidence, and the continued-stay guide covers update timing.

What record evidence supports each LOCUS or CALOCUS-CASII dimension?

Each dimension needs dated, observable facts from the review window, written in the record before the denial. The table pairs each LOCUS dimension with its CALOCUS-CASII counterpart and describes, in plain words, the evidence that supports a rating. It does not reproduce the instruments’ rating anchors, which are licensed and should come from your own copy.

Where do reviewers and programs most often disagree on LOCUS ratings?

Disagreements cluster in a few places: risk of harm rated from an old note, recovery environment rated as if the patient were still inside the program, treatment history that leaves out failed lower levels, and engagement read as a reason to step down. Each one has a direct answer in the record.

• Risk of harm from old notes. The reviewer rated from the intake or an early note. Answer with risk assessments and incidents dated inside the review window; ratings are meant to reflect the current picture.
• Recovery environment rated from inside the program. LOCUS says people in locked or protected residential settings are rated on the conditions they would face outside. Document who is home after program hours.
• Treatment history that skips failed step-downs. List each prior episode by level and outcome; a lower level that ended in an emergency visit or readmission is the core of this dimension.
• Engagement used against the patient. Good engagement can lower one rating, but it does not offset high risk or an unsafe environment.

How should a peer-to-peer discussion use the dimension ratings?

Bring the side-by-side ratings and ask the reviewer which dimension drives the lower level. Then give the dated facts for that dimension and ask whether the rating changes. Ending the call with the reviewer’s revised ratings, or the specific facts still missing, gives the written appeal a precise target either way.

For a CALOCUS-CASII dispute, ask for a reviewer in child and adolescent psychiatry; for employer plans, the plan must consult a health care professional with appropriate training and experience in the field when it decides the appeal (29 CFR 2560.503-1(h)(3)(iii)). Record the reviewer’s name, credentials, the ratings discussed and the time of the call.

The peer-to-peer guide covers scheduling and the one-page brief, and the PHP appeal letter template gives the written structure if the call does not settle it.