Behavioral

An indicator showing that a member is enrolled in a behavioral health home program, a Medicaid health home model specifically designed for individuals with serious mental illness or substance use disorder that provides comprehensive care coordination across physical and behavioral health services.

The total number of calendar days a member remained admitted to an inpatient psychiatric or substance use residential treatment facility, calculated from admission date through discharge date. Length of stay is a core utilization metric used in concurrent review, cost modeling, and benchmarking against evidence-based length of stay guidelines.

An indicator used in compliance reporting to confirm that a health plan's behavioral health provider network meets regulatory time-and-distance or appointment-availability standards, a key area of regulatory scrutiny under state parity enforcement programs.

An indicator showing that a member failed to attend a scheduled behavioral health appointment without prior cancellation, used to calculate no-show rates by provider, modality, and population segment, which are strong predictors of treatment disengagement and are commonly addressed through reminder and outreach interventions.

A composite score derived from a standardized behavioral health outcome survey instrument such as the OQ-45 or DLA-20, administered at intake and at defined intervals throughout treatment to measure clinical progress and inform treatment plan adjustments.

An indicator used in compliance reporting to confirm that a specific benefit design, cost-sharing structure, or utilization management practice applied to behavioral health services is comparable to that applied to medical and surgical benefits, as required under the Mental Health Parity and Addiction Equity Act.

A code segmenting members into behavioral health risk tiers based on diagnosis severity, utilization history, and predictive risk scoring, used to prioritize case management resources and target population health interventions at the members most likely to benefit.

A code identifying the professional licensure or credential type of a behavioral health provider, such as Licensed Clinical Social Worker, Licensed Professional Counselor, Psychiatrist, Psychiatric Nurse Practitioner, or Licensed Marriage and Family Therapist. This field affects scope-of-practice validation, billing eligibility for specific CPT codes, and network adequacy analysis.

The total number of unique members actively assigned to or treated by a specific behavioral health provider during a defined period, used in provider capacity analysis, network adequacy modeling, and identification of providers approaching panel capacity limits.

An indicator used in value-based contracting to identify whether a behavioral health provider or facility met the performance thresholds required to qualify for a quality-based bonus payment under a payer's pay-for-performance arrangement.

The total number of discrete treatment sessions delivered as part of a behavioral health encounter or episode of care, used to track utilization against authorized session limits, measure treatment engagement, and support outcomes research correlating session frequency with clinical improvement. Session counts are commonly tracked separately for individual therapy, group therapy, and family therapy modalities within the same episode.

An indicator showing that a member receiving behavioral health services was screened for social determinants of health factors such as housing instability, food insecurity, or transportation barriers that may impact treatment access and adherence, supporting integrated whole-person care models increasingly required under value-based behavioral health contracts.

An indicator showing that a payer's step therapy requirement for a psychiatric medication was overridden based on documented clinical justification or prior treatment history. This field is used in formulary compliance reporting and prior authorization workflow analysis for behavioral health pharmacy benefits.

The number of telephonic outreach attempts made by a care coordinator or case manager to engage a member following identification through a risk stratification model, behavioral health screening referral, or missed appointment, used to evaluate outreach program intensity and effectiveness.

An identifier for a Board Certified Behavior Analyst overseeing an applied behavior analysis treatment plan, used to validate supervision requirements and link treatment plans to the credentialed clinician responsible for clinical oversight.

An indicator showing that a prescribing provider holds the federal waiver authorizing them to prescribe buprenorphine for opioid use disorder treatment. This field supports network adequacy analysis for medication-assisted treatment access.

A standardized score quantifying the level of stress and burden experienced by a family member or caregiver supporting an individual with significant behavioral health or substance use needs, used in family support program targeting and respite care eligibility determination.

A code identifying the specific type of behavioral health case management contact delivered, such as care coordination, benefits navigation, housing assistance, or crisis safety planning, distinguishing these non-clinical support encounters from billable clinical therapy sessions.

A standardized or facility-specific score reflecting a member's current behavioral or psychiatric stability, used to inform level-of-care step-down decisions, discharge readiness assessments, and risk stratification for case management prioritization.

An indicator showing whether a member carries both a behavioral health diagnosis and a substance use disorder diagnosis simultaneously, identifying the population requiring integrated dual-diagnosis treatment programs. Members with co-occurring disorders typically have higher utilization, more complex care coordination needs, and are a key population health segment for behavioral health analytics.