Level-of-care criteria crosswalk builder

How do I build a crosswalk with this tool?

Choose the level of care and the review type, then the starting rows: common factors, ASAM dimensions or LOCUS dimensions. Quote the denial reason and name the criteria the plan cited. For each row, add the document, day and page that answers it, and set the status. The crosswalk updates as you type.

1. 01Pick the level of care requested and whether this is an admission, continued-stay or retrospective review.
2. 02Choose the starting rows that match the criteria family named in the notice, then rename each row to the plan's own wording.
3. 03Quote the denial reason exactly as the notice states it, and name the criteria set, edition and section.
4. 04For each factor, cite the record that answers it: document, relative day and page. Use one line per record.
5. 05Mark each row honestly, add a next step for every gap, then print, copy or download the crosswalk as .txt or .csv.

What is a level-of-care criteria crosswalk?

It is a working table that lines up each criterion the plan applied with the evidence that meets it, so the clinician, the biller and the reviewer can all check the argument in one place. In an appeal packet it sits right after the letter, and every row points to a numbered enclosure.

Reviewers decide level-of-care requests against a criteria set: a published one such as the ASAM Criteria for substance use treatment or LOCUS for adult mental health, or the plan's own guideline. A letter that answers the criteria row by row is easier to verify than a narrative summary of the chart, and the crosswalk forces that structure before anyone drafts. The level-of-care denial guide explains the wider appeal.

How should I mark a row met, partly met or not documented?

Mark a row met only when a dated record from the period at issue answers it. Partly met means the record supports part of it, or only for some dates. Not documented means you could not find support. A gap is useful: either the record exists somewhere you have not cited, or the letter should not argue that factor.

• Cite the record from the dates at issue; admission notes rarely prove a continued-stay date.
• Prefer observable facts and measures to adjectives such as severe or unstable.
• Ask the treating clinician about every partly met row before the letter is drafted.
• Use not applicable for factors the plan's criteria do not test at this level.

What if the plan has not said which criteria it used?

Ask in writing. For employer plans, the documents relevant to the claim, including any guideline relied on, must be provided free on request, and parity rules require plans to disclose medical-necessity criteria for mental health and substance use benefits. Build the crosswalk on common factors meanwhile, then rename the rows when the criteria arrive.

The ERISA claims rule covers documents and the internal rule or guideline relied on (29 CFR 2560.503-1), and the parity rule covers disclosure of medical-necessity criteria (29 CFR 2590.712(d)). Medicaid managed care plans must give the enrollee the case file, including medical records and new evidence, free of charge (42 CFR 438.406). The criteria request letter drafts the request. If the deadline arrives first, file on time and state when you asked.

Where does the crosswalk go in the appeal packet?

Directly after the appeal letter and before the records. Number the enclosures in the order the crosswalk cites them, so a reviewer can check each row in seconds. Bring the three strongest rows to the peer-to-peer, and keep the crosswalk for the next level of appeal if the denial is upheld.

A typical level-of-care packet runs: the appeal letter signed by the treating clinician, the crosswalk, the denial notice, then the evaluations, treatment-plan updates, progress notes, risk assessments, attendance logs and discharge plan the crosswalk cites. The peer-to-peer prep sheet turns the top rows into talking points.