Colorado providers will soon see an update to the evidence-based criteria used to support mental health level-of-care medical necessity reviews.

Effective April 11, 2026, and in compliance with Colorado General Assembly. (2025). HB25-1002: Medical Necessity Determination Insurance Coverage, Evernorth^® Behavioral Health (Evernorth) will adopt the Level of Care Utilization System (LOCUS) for customers aged 19 and older and the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII) criteria for customers aged 6 through 18.

LOCUS and CALOCUS–CASII criteria will be used for guidance when conducting mental health level-of-care medical necessity reviews for your patients enrolled in U.S. commercial and individual health plans in Colorado, unless federal or state law requires the use of other specifically identified clinical criteria.

What this means to you
Adoption of LOCUS and CALOCUS-CASII criteria supports a consistent application of evidence-based standards, helping ensure that treatment decisions consider practices shown to be effective for mental health disorders. They promote consistency, transparency, and alignment with state requirements while continuing to support your clinical judgment.

Note: Only the source of the criteria for mental health level-of-care medical necessity reviews is changing. Our medical necessity review process is NOT changing.

In addition to LOCUS and CALOCUS-CASII criteria, we will continue using the resources below to support medical necessity determinations when appropriate.

• The ASAM Criteria^® – Developed by the American Society of Addiction Medicine, these criteria guide Evernorth medical necessity reviews for substance use disorder levels of care for all health plans, unless contractual requirements or federal or state law requires other clinical criteria.
• Evernorth and Cigna Healthcare^® coverage policies ‒ For autism spectrum disorders/pervasive developmental disorders: assessment and treatment, intensive behavioral interventions, transcranial magnetic stimulation, and complementary and alternative medicine.
• Evernorth Behavioral Health Authorization and Billing Resource.
• State and federal regulations and licensing standards.

Online resources
You can access our evidence-based criteria, clinical support tools, and resources ‒ including the LOCUS and CALOCUS-CASII criteria ‒ in the “Supporting Behavioral Websites” section of the Coverage Policies page on the Evernorth Provider website (Provider.Evernorth.com).

Additional information

If you have any questions, please call Provider Service at 800.926.2273.