Curated is an independent behavioral health care navigation program. A named, licensed navigator stays with each member across every BH episode for the duration of their enrollment. That continuity, applied across 13 clinical areas and a quality-scored provider database, produces measurable reductions in readmission, treatment abandonment, and misplaced care. The 30-day readmission warranty on SUD residential and acute psychiatric episodes is fee-at-risk: we forfeit our earned navigation fees if a navigated member is readmitted.
The pilot runs 90 days on a defined population. Claims-verified scorecard at days 30, 60, and 90. No multi-year commitment. No termination penalty. The scorecard is the decision document: continue, expand, or walk away.
1,000 covered lives (employees + dependents). This floor produces enough episode volume to generate a statistically meaningful scorecard within 90 days. Based on national BH utilization rates (roughly 23% of commercially insured adults received mental health services in 2023, per NSDUH 2023), with approximately 5-8% of those requiring higher-acuity navigation-eligible services (residential, acute psychiatric, IOP/PHP, crisis), a 1,000-life cohort should generate 50-80 navigation-eligible episodes during the 90-day measurement window.
Members with 2+ BH claims (ICD-10 F01-F99) in the prior 12 months. These are members already in the system, often cycling between providers without coordination.
Members who have exhausted EAP sessions (typically 6-8 per situation) and need ongoing BH care beyond what the EAP was designed to provide. Warm handoff from EAP to navigator.
Members with BH episode costs exceeding $15,000 in the prior 12 months. Residential SUD, acute psychiatric inpatient, and repeat crisis stabilization are the primary drivers.
| Clinical Area | ICD-10 Range | Typical Episode |
|---|---|---|
| Acute psychiatric | F20-F29, F30-F39 | Inpatient stabilization, 5-14 days |
| Residential SUD | F10-F19 | 28-90 day residential treatment |
| IOP / PHP | F10-F19, F30-F39, F40-F48 | 9-20 hours/week structured programming |
| MAT programs | F11.xx (opioid), F10.xx (alcohol) | Buprenorphine, naltrexone, ongoing management |
| Eating disorders | F50.xx | Residential, PHP, or outpatient depending on severity |
| PTSD / trauma | F43.1x | Evidence-based outpatient (CPT, EMDR, PE) |
| Adolescent BH | F90-F98, F30-F39 | Dependent members under 18, all levels of care |
| Dual diagnosis | F10-F19 + F20-F39 | Co-occurring SUD and psychiatric, integrated treatment |
| Detox | F10-F19 with .2x (withdrawal) | Medically managed withdrawal, 3-7 days |
| Crisis stabilization | F43.0, F32.xx | 23-hour observation, crisis residential |
| Outpatient therapy | F30-F48 | Weekly or biweekly sessions, ongoing |
| Neuropsych | F06-F09, R41.xx | Testing, evaluation, treatment planning |
| Co-occurring medical | F-codes + medical primaries | BH complicating medical episode (cardiac, oncology, chronic pain) |
Curated does not navigate forensic psychiatric episodes, court-mandated treatment where the navigator cannot influence placement, or intellectual/developmental disability services (ICD-10 F70-F79). Members with active danger to self or others are triaged to 911 or crisis services before navigation begins.
The pilot is designed to be operationally lightweight. We do not require EHR integration, benefits platform access, or technology buildout. The data requirements are standard for any vendor evaluation.
| Prerequisite | Detail | Timeline |
|---|---|---|
| Claims data feed | 12 months of BH claims (ICD-10 F01-F99 primary or secondary diagnosis). Standard 837/835 format or flat file extract from TPA. De-identified is acceptable for baseline analysis; identified data required for active navigation. Monthly refresh during pilot. | Pre-launch |
| Eligibility file | Current enrollment roster for pilot population. Standard 834 format or equivalent. Monthly refresh. Includes dependent status, plan type, and geographic location. | Pre-launch |
| BH provider network | Current in-network BH provider directory or network access summary. This helps us identify gaps in your existing network that our quality-scored providers can fill. Not required for launch, but improves placement speed. | Week 1-2 |
| Referral pathway | At least one active referral channel: EAP warm handoff (preferred), HR direct referral, member self-referral via employer communication, or claims-triggered outreach. Multiple channels increase engagement. | Pre-launch |
| BAA execution | Standard HIPAA Business Associate Agreement. We provide our template or execute yours. Covers PHI handling for navigation, episode tracking, and outcome reporting. | Pre-launch |
| Communication channel | Method to notify eligible members about navigation availability. Options: benefits portal announcement, HR email, EAP referral script, open enrollment materials. We provide copy and collateral. | Week 1-3 |
Quality-scored behavioral health programs across all 13 clinical areas. This is the IP. Each program is evaluated on completion rates, readmission history, clinical staffing ratios, accreditation status (CARF/Joint Commission), and patient outcome data where available. We do not own or operate any treatment facility. The navigator's only incentive is the right placement. Network is built geography-first: we map the pilot population's ZIP distribution and ensure vetted coverage within 60 miles for outpatient and within 150 miles for residential (residential SUD members routinely travel). Where no vetted program exists in range, we vet a new program before placement or disclose the gap to the employer. Database is re-evaluated quarterly; programs losing accreditation or falling below outcome thresholds are removed.
Licensed clinical navigator (LCSW, LPCC, or equivalent) assigned to each member at first episode. That navigator persists across every subsequent BH episode for the duration of enrollment. Not a call center. Not a new intake each time. The same person who knows their history, medications, family situation, and prior treatment response.
Every navigated episode is tracked from referral through placement, treatment, completion, and 30-day post-discharge monitoring. Status visible to employer (de-identified aggregate) and to the navigator managing the case.
Navigator coordinates between member, provider program, employer benefits team, and (where applicable) EAP. Includes pre-authorization support, benefits verification, family communication, and step-down planning.
30-day post-discharge monitoring on every SUD residential and acute psychiatric episode. Navigator maintains contact cadence (days 3, 7, 14, 21, 30). Claims-verified readmission tracking. This monitoring produces the data that activates the warranty at scale.
Claims-verified performance scorecard at days 30, 60, and 90. Metrics agreed before launch. No self-reported surveys. No engagement-only reporting. The scorecard measures what happened to cost and clinical outcomes, not how many people answered the phone.
Most BH navigation programs assign a new coordinator each time a member calls. The member re-tells their story. The coordinator re-reads the chart. Context is lost. The member drops out. Curated inverts that model. One navigator. Every episode. The continuity itself is therapeutic, and the data it produces across episodes is the moat.
Navigator is assigned based on three factors: (1) clinical area expertise -- SUD-heavy caseloads go to navigators with SUD specialization, (2) geographic alignment -- navigator knows the provider landscape in the member's region, (3) caseload capacity -- no navigator exceeds 18 active episodes. Once assigned, the navigator stays with that member across every subsequent episode. Reassignment only happens if the navigator leaves the organization, and handoff includes a full case transfer with the incoming navigator.
Every program in the quality-scored database is evaluated on five gates: (1) accreditation status (CARF or Joint Commission preferred), (2) completion rates above 65% for residential, (3) staff-to-patient ratios meeting or exceeding state minimums, (4) no active disciplinary actions from state licensing boards, (5) willingness to share outcome data with Curated for ongoing quality monitoring. Programs that fail any gate are removed from the network. No volume incentives. No referral fees. The navigator's only financial interest is the member completing treatment.
When a member enters a second or third BH episode (common in dual diagnosis, chronic SUD, and treatment-resistant depression), the same navigator picks up. No new intake. No lost context. The navigator already knows the medication history, the family dynamics, which facilities worked and which didn't, and what the member's actual barriers to completion are.
Each clinical area has its own vetting criteria, provider quality standards, and outcome benchmarks. The navigator is trained across all 13, with clinical director supervision on complex cases.
Inpatient stabilization for psychotic episodes, severe mood disorders, and acute suicidality. Navigator coordinates admission, communicates with family, and manages step-down to PHP/IOP or outpatient. Average episode: 5-14 days. Warranty-eligible.
28-90 day residential substance use treatment. Navigator manages the full arc: intake, family engagement, mid-treatment check-ins, discharge planning, and 30-day post-discharge monitoring. This is the highest-cost, highest-readmission BH episode. Warranty-eligible.
Intensive outpatient (9+ hours/week) and partial hospitalization (20+ hours/week). Often a step-down from residential or inpatient. Navigator ensures the transition doesn't become a dropout point.
Medication-assisted treatment for opioid use disorder (buprenorphine, naltrexone) and alcohol use disorder. Navigator monitors adherence, coordinates with prescribing provider, and manages the extended stabilization period (6-24 months).
Residential, PHP, and outpatient programs for anorexia, bulimia, and binge eating disorder. Specialized vetting criteria: dietitian-to-patient ratios, medical monitoring capability, evidence-based protocols (FBT for adolescents, CBT-E for adults).
Evidence-based outpatient treatment: Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR), Prolonged Exposure (PE). Navigator matches member to provider with specific modality expertise.
Dependent members under 18 across all levels of care. Includes parent/guardian coordination, school liaison where appropriate, and age-specific facility vetting (staff ratios, accreditation, outcome tracking).
Co-occurring substance use and psychiatric disorders. Requires integrated treatment programs (not sequential). Navigator vets for true integration, not co-located but separate treatment tracks.
Medically managed withdrawal. 3-7 days. Navigator ensures placement in medically appropriate setting (hospital-based vs. standalone) based on substance, withdrawal severity, and medical co-morbidities. Coordinates immediate step-down to residential or IOP.
23-hour observation and crisis residential (up to 72 hours). Navigator is the continuity point between crisis episode and ongoing treatment. Without navigation, crisis stabilization often ends in discharge with a phone number and no follow-up.
Ongoing weekly or biweekly therapy. Navigator role here is matching: finding providers with specific clinical expertise (not just availability), verifying credentials, and monitoring engagement. Low-cost per session, but high-volume and high-dropout.
Neuropsychological testing and evaluation. Long wait times (often 6-12 weeks). Navigator accelerates placement through quality-scored database relationships and coordinates results with treatment team.
Behavioral health complications in medical episodes: depression in cardiac rehab, anxiety in oncology, substance use in chronic pain management. Navigator coordinates between BH and medical treatment teams.
The staffing model scales with pilot population. A 1,000-life pilot requires different resources than a 50,000-life deployment. Below is the pilot-phase staffing plan.
| Role | Credential | Ratio / Count | Responsibility |
|---|---|---|---|
| Navigator | LCSW, LPCC, or equivalent state licensure | 1 per 15-18 active episodes (up to 30 dormant) | Member-facing. Episode management, provider coordination, family communication, post-discharge monitoring. Named assignment, persistent across episodes. |
| Clinical Director | PhD / PsyD / MD with BH specialization | 1 per pilot | Navigator supervision, complex case review, provider network quality oversight, clinical protocol governance, crisis escalation authority. |
| Founder | M.S. Applied Behavioral Analysis | 1 (direct involvement during pilot) | Employer relationship, scorecard review, strategic oversight, escalation point. Direct involvement in every pilot engagement. 200,000+ patients managed across BH/SUD/MAT settings. |
Navigator compensation: $65,000-$85,000 annualized (pro-rated for pilot). Clinical director: $140,000-$180,000 annualized (part-time allocation for pilots under 5,000 lives). Technology infrastructure (Supabase): $500-$2,000/month. Provider network development and maintenance: sunk cost (pre-built). Total pilot delivery cost for a 1,000-life engagement: approximately $25,000-$40,000 over 90 days.
The technology is infrastructure, not product. We don't sell a platform. We use Supabase (PostgreSQL-backed, SOC 2 Type II compliant, HIPAA-eligible) for member and episode tracking, referral management, and outcome recording. The technology serves the navigator. It does not replace the navigator.
| Capability | Function |
|---|---|
| Member record | Demographics, plan information, clinical history, navigator assignment, episode log. Row-level security ensures navigators see only their assigned members. |
| Episode tracker | Referral source, clinical area, provider placement, treatment dates, completion status, discharge disposition, 30-day readmission flag. Each episode linked to member record for chain visibility. |
| Referral management | Inbound referral capture (EAP, HR, self, claims-triggered), assignment queue, navigator workload balancing, status tracking through placement. |
| Outcome recording | Completion/non-completion, reason codes for dropout, readmission events (date, facility, diagnosis), cost data from claims reconciliation. |
| Scorecard generator | Automated scorecard production from episode and outcome data. Pre-configured for agreed metrics. PDF export for employer distribution. |
| Provider directory | Quality-scored provider programs by clinical area, geography, capacity, accreditation status, and historical outcome data. Navigator-facing. Not member-facing. |
The claims data feed and eligibility file are the only technical inputs. Everything else runs on our infrastructure.
The scorecard is the decision document. Every metric has a definition, a data source, a baseline (from your claims), and a target. No self-reported satisfaction surveys. No engagement-only metrics. The scorecard measures what happened to cost and outcomes.
| Metric | Definition | Source | Baseline | Target |
|---|---|---|---|---|
| Readmission rate (30-day) | % of navigated SUD residential and acute psychiatric episodes resulting in readmission to the same level of care (residential or inpatient) within 30 calendar days of discharge, for a diagnosis within the same ICD-10 chapter as the index episode | Claims data + navigator episode tracking | Your prior 12-month rate (industry: 15-20%) | <10% |
| Program completion rate | % of residential episodes where member remains through clinically recommended discharge (not AMA or early termination); reported separately for IOP/PHP | Provider discharge records + navigator verification | Your prior 12-month rate (industry: 50-60% residential) | >80% residential, >90% IOP |
| Engagement rate | % of referred members who complete navigator intake and accept at least one provider match | Navigator episode tracking | N/A (new program) | >65% |
| Cost per episode | Average allowed amount per navigated BH episode vs. non-navigated baseline, by clinical area | Claims data reconciliation | Your prior 12-month average by clinical area | 15-25% reduction |
| Navigator continuity | % of multi-episode members served by the same navigator across all episodes | Navigator assignment records | N/A (new program) | >90% |
| Time to placement | Calendar days from navigator intake to confirmed provider admission/first appointment | Navigator episode tracking | N/A (new program) | <5 days residential, <10 days outpatient |
| Member satisfaction | Post-episode survey (5-point scale) for navigated members who complete treatment. Supplementary, not primary. | Member survey (post-discharge) | N/A | >4.2 / 5.0 |
| Tier | Covered Lives | PEPM | Includes |
|---|---|---|---|
| Pilot | First client | $3-4 | Navigation, episode tracking, scorecard, founder involvement. Testimonial clause. |
| Standard | <10,000 | $6-7 | Full navigation + episode spread (shared savings on cost reduction) |
| Mid-market | 10,000-25,000 | $5-6 | Full navigation + episode spread + quarterly business review |
| Enterprise | 25,000-50,000 | $4-5 | Full navigation + episode spread + dedicated clinical director |
| National | 50,000+ | $3-4 | Full navigation + episode spread + gain-share year 2+ |
Monthly per-eligible-member fee. Covers navigator staffing, clinical oversight, technology, provider network maintenance, and scorecard production. Invoiced monthly.
Shared savings on cost reduction per navigated episode vs. baseline. Activated after baseline is established (typically 60 days into pilot). Split: 60% employer / 40% Curated on documented savings.
Performance-based upside in full contract. Tied to sustained readmission reduction and cost trend improvement vs. baseline. Not active during pilot. Replaces episode spread at scale.
| Line Item | Amount | Notes |
|---|---|---|
| Pilot PEPM revenue (90 days) | $45,000-$60,000 | $3-4 PEPM x 5,000 lives x 3 months |
| Episode spread (est.) | $15,000-$40,000 | Dependent on episode volume and baseline cost |
| Our delivery cost | ($35,000-$55,000) | 2-3 navigators + clinical director allocation + tech |
| Pilot margin | $10,000-$30,000 | Margin improves with volume. First pilot may break even. |
Average BH readmission costs $12,000-$18,000 per event (HCUP Statistical Brief #274, AHRQ). At a 5,000-life plan with 250-400 BH episodes annually, reducing readmission from 17% to under 10% prevents 18-28 readmissions per year. Conservative value: $200,000-$500,000 in avoided readmission costs. The PEPM investment at $3-4 is $180,000-$240,000 annually. Expected ROI: 1.5-3x in year one on readmission reduction alone, before counting improved completion rates, reduced crisis utilization, and lower out-of-network leakage.
The 30-day readmission warranty on SUD residential and acute psychiatric episodes is the most compelling element of the Curated model. It is also the element that requires the most actuarial discipline. Activating a warranty before we have enough measured episodes to price the risk accurately would be a marketing gimmick, not a financial commitment. We don't do gimmicks.
| Element | Detail |
|---|---|
| Trigger | Navigated member is readmitted to SUD residential or acute psychiatric inpatient within 30 days of discharge for a condition within the same clinical area that should have been addressed during the initial episode. |
| Warranty trigger | Curated forfeits the full episode navigation fee for that member. The readmission claim continues through the employer's plan and TPA — Curated does not process or pay medical claims. Our exposure is limited to earned fees, not medical costs. |
| Exclusions | Member left against medical advice (AMA). New, unrelated diagnosis. Member non-compliance with prescribed aftercare (documented by navigator). Trauma or acute event unrelated to original episode. |
| Volume cap | 10% of total navigated warranty-eligible episodes per contract year. If warranty triggers exceed 10% of volume, we forfeit fees on the first 10% and the contract triggers a joint review with actuarial reassessment. |
| Reserve methodology | 15% of earned navigation fees held as performance reserve per warranty-eligible episode. Reserve is against fee forfeiture exposure, not medical claims. Reserve reviewed quarterly. Excess reserves above 150% of actuarial estimated fee-forfeiture liability (as determined by the independent actuarial review referenced above) may be released as gain-share to employer at the next quarterly review. |
| Fee forfeiture process | Readmission identified via claims data or navigator monitoring. Curated notifies employer with supporting documentation and credits the forfeited navigation fee against the next invoice cycle within 30 days of validated trigger. |
The pilot produces the data that makes the warranty actuarially sound. Every navigated episode during the pilot is measured against the same readmission criteria that the warranty will use. By day 91, you and your actuary have real data on our readmission rates, not projections from a pitch deck. The 100-episode threshold typically requires 2-3 pilot engagements or one large-employer pilot at 10,000+ lives.
The day-91 scorecard produces one of three outcomes. Each is documented. Each is your decision.
Extend the pilot for an additional 90 days at the same PEPM and population scope. Appropriate when early results are directionally positive but the episode volume is too small for confident conclusions. No cost increase. Same scorecard discipline.
Transition from pilot to full contract. Population expands to all eligible members (or a larger defined segment). PEPM adjusts to volume tier. Episode spread and gain-share terms activated. Warranty timeline begins (100-episode countdown from expansion date). 12-month initial term with annual renewal. 90-day termination notice.
Scorecard results don't justify continuation. You keep all data: baseline analysis, claims profile, readmission patterns, provider network assessment. No termination fee. No penalty. No obligation. The data you retain has independent value for vendor evaluation and benefits strategy.
| Term | Detail |
|---|---|
| Duration | 12-month initial term. Annual renewal. 90-day termination notice by either party. |
| PEPM | Volume-tiered per pricing table (Section 10). Locked for initial 12-month term. |
| Episode spread | 60/40 split (employer/Curated) on documented savings per navigated episode vs. agreed baseline. |
| Gain-share | Year 2+. Tied to sustained readmission reduction and cost trend improvement. Terms negotiated based on year-one performance. |
| Warranty | Activates after 100 measured warranty-eligible episodes. Terms per Section 11. |
| Scorecard | Monthly reporting. Quarterly business review with clinical director and founder. |
| Exclusivity | Non-exclusive. You may run concurrent BH navigation programs. We measure against the same baseline regardless. |
The legal framework is standard for a HIPAA-covered vendor relationship with a self-funded employer health plan. No novel legal structures are required.
For self-funded ERISA plans, Curated operates as a service provider to the plan, not as a fiduciary. Navigation recommendations are advisory. Curated does not make benefit determinations, deny claims, or administer plan benefits. The employer (or TPA) retains all fiduciary responsibility for plan administration. Curated's scorecard and outcome data may serve as a fiduciary compliance artifact demonstrating prudent oversight of BH benefits.
The following data sources inform the baselines, benchmarks, and estimates used throughout this pilot plan. All employer-specific figures will be replaced with your actual claims data during the baseline analysis phase.
| Source | Use | Access |
|---|---|---|
| SAMHSA NSDUH (2023) | National BH utilization rates, SUD prevalence, treatment gap estimates. Basis for pilot population sizing. | samhsa.gov/data |
| SAMHSA TEDS (2023) | Treatment episode outcomes, readmission rates by substance and level of care, completion rates for residential and outpatient SUD. | samhsa.gov/data/teds |
| SAMHSA N-SSATS | Facility-level treatment capacity, services offered, accreditation status. Used in provider network development. | samhsa.gov/data/nssats |
| CMS BH utilization data | Medicare and Medicaid BH utilization trends, cost benchmarks by service type, readmission patterns. Cross-reference for commercial estimates. | data.cms.gov |
| AHRQ HCUP | Hospital readmission statistics, cost per BH admission, statistical briefs on behavioral health utilization. | hcup-us.ahrq.gov |
| Milliman Health Cost Guidelines (2024) | Commercial cost benchmarks by episode type, BH cost trends, PEPM benchmarking. | Licensed. Available on request. |
| State licensing boards | BH facility licensing status, disciplinary history, operational capacity. Verified per-state for provider network vetting. | State-specific portals |
| CARF International | Accreditation status for BH and SUD treatment facilities in the quality-scored provider database. | carf.org/providerSearch |
| Joint Commission | Accreditation status for hospitals and BH facilities. Cross-referenced with CARF for full quality picture. | qualitycheck.org |
| BLS Occupational Outlook | Social worker and clinical counselor compensation benchmarks for navigator staffing estimates. | bls.gov/ooh |
| Founder operational data | 200,000+ patients managed across BH/SUD/MAT settings. 80%+ residential completion. Single-digit readmission. 13-location health system built, scaled, and exited. | Internal. Verified on request. |