Psychiatric Residential Treatment Facility (PRTF): Aligning Care Efficiencies with Effective Treatment. BHM Healthcare Solutions
|
|
- Bernice Houston
- 8 years ago
- Views:
Transcription
1 Psychiatric Residential Treatment Facility (PRTF): Aligning Care Efficiencies with Effective Treatment 1
2 Presentation Objectives Attendees will have a thorough understanding of Psychiatric Residential Treatment Facility (PRTF) Services from an authorization perspective Attendees will gain an understanding of the importance of Medical Necessity Criteria as it applies to PRTF Attendees will learn key questions to ask through the authorization process 2
3 Understanding Medical Necessity Criteria (MNC) According to a presentation by NC Department of Health and Human Services (Division of Medical Assistance) Medical necessity is individual, but some generally accepted components are: Intended to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a diagnosable condition that threatens life, causes pain or suffering, or results in illness of infirmity Treatment is expected to improve the condition or levels of functions in relationship to the presenting diagnosis 3
4 Understanding Medical Necessity Criteria (MNC) General Criteria Covered Medicaid shall cover procedures, products, and services related to this policy when they are medically necessary, and: a. the procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary s needs; b. the procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; and c. the procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary s caretaker, or the provider. 4
5 Understanding PRTFs Psychiatric Residential Treatment Facilities (PRTFs) provide non-acute inpatient facility care for NC Medicaid recipients (under 21 years of age) who have a mental illness and/or substance abuse/dependency and need 24-hour supervision and/or specialized interventions 5
6 Understanding PRTFs PRTFs provide: Planned regimen of 24-hour professionally directed evaluation, observation, medical monitoring and addiction treatment in an inpatient setting. They are appropriate for adolescents whose subacute biomedical and emotional, behavioral or cognitive problems are so severe that they require inpatient treatment, but who do not need the full resources of an acute care hospital. 6
7 Direct admission to a Level III.7 program is available for the adolescent who meets two of Dimensions 1-6 with at least one of the stability specifications in Dimensions 1 (acute intoxication and /or withdrawal) OR Dimension 2 (biomedical conditions or problems) OR Dimension 3 (emotional, behavioral or cognitive conditions). Dimensional Substance Abuse Admission Criteria DIMENSION 1: Acute Intoxication and/or Withdrawal DIMENSION 2: Biomedical Conditions and Complications DIMENSION 3: Emotional, Behavioral or Cognitive Conditions and Complications DIMENSION 4: Readiness to Change DIMENSION 5: Relapse, Continued Use or Continued Problem Potential DIMENSION 6: Recovery Environment 7
8 Dimensional Admission Criteria: Level III.7 DIMENSION 1: Acute Intoxication and/or Withdrawal 1. The adolescent is experiencing or at risk of acute or sub acute intoxification or withdrawal with moderate to severe signs and symptoms. DIMENSION 2: Biomedical Conditions and Complications 1. The adolescents status is characterized by one of the following: a. A biomedical complication of addiction or co-occurring biomedical condition that requires active nursing or medical monitoring but does not require the resources of an acute care hospital b. Continued alcohol or drug use places the adolescent at imminent risk of serious damage to physical health because of a biomedical condition (i.e.. brittle diabetes, pregnancy or HIV), which requires active nursing or medical monitoring 8
9 Dimensional Admission Criteria: Level III.7 DIMENSION 3: Emotional, Behavioral, or Cognitive Conditions and Complications 1. The adolescent s status features one or more of the following: a. Dangerousness/Lethality-The adolescent is at moderate (and unpredictable) risk of imminent harm (self or others) and needs highintensity 24-hour monitoring or treatment, or secure containment, for safety. b. Interference with Recovery Efforts- Severe interference and distraction with recovery efforts requires highintensity residential treatment to stabilize emotional or behavioral problems and support engagement. DIMENSION 3: (cont d) c. Social Functioning- Significant impairments with severe symptoms (poor impulse control, disorganization, etc) that seriously impair functioning in family, social, school or work settings (repeatedly running away, seriously aggressive or disruptive behaviors) and cannot be managed at a less intensive level of care. d. The adolescent evidences moderate to severe difficulties with activities of daily living and requires 24-hour supervision and high-intensity staff assistance. e. The adolescent s history (combined with the present situation) predicts destabilization without high-intensity residential treatment. 9
10 Dimensional Admission Criteria: Level III.7 DIMENSION 4: Readiness to change 1. The adolescent s status is characterized by one of the following: a. The adolescent has not related his or her problems to substance use or has not accepted the need for change b. The adolescent has not demonstrated sufficient readiness to change and thus needs intensive motivating strategies, activities and processes available only in a 24-hour high-intensity structured setting 10
11 Dimensional Admission Criteria: Level III.7 DIMENSION 5: Relapse, Continued Use or Continued Problem Potential DIMENSION 6: Recovery Environment 1. The adolescent s status is characterized by one of the following: a. The adolescent is unable to interrupt a high severity or high frequency pattern of use with imminent severe risk of dangerous consequences without highintensity 24-hour interventions b. The modality of treatment requires this level of care (i.e., agonist or antagonist therapy, monitoring, case management and documentation needed to arrange alternative level of care or resource) 1. The adolescent s status is characterized by one of the following: a. The adolescent s living environment is dangerous to his or her recovery, and he or she requires residential treatment to promote recovery goals or for protection b. The adolescent requires this LOC to help him or her establish a successful transition to a less intensive level of care. 11
12 All of the following must be met: Managing Care: PRTF Admission Criteria Are their symptoms consistent with a DSM-IV-TR (Axis I-V) diagnosis that requires, and can reasonably be expected to respond to, therapeutic intervention? Yes No 12
13 All of the following must be met: Managing Care: PRTF Admission Criteria The child/adolescent is experiencing emotional or behavioral problems in the home, community and/or treatment setting and is not sufficiently stable either emotionally or behaviorally, to be treated outside of a highly structured 24-hour therapeutic environment. Yes No 13
14 All of the following must be met: Managing Care: PRTF Admission Criteria The child/adolescent demonstrates a capacity to respond favorably to rehabilitative counseling and training in areas such as problem solving, life skills development, and medication compliance training. Yes No 14
15 All of the following must be met: Managing Care: PRTF Admission Criteria The child/adolescent has a history of multiple hospitalizations or other treatment episodes and/or recent inpatient stay with a history of poor treatment adherence or outcome. Yes No 15
16 All of the following must be met: Managing Care: PRTF Admission Criteria Less restrictive or intensive levels of treatment have been tried and were unsuccessful, or are not appropriate to meet the individual s needs Yes No 16
17 All of the following must be met: Managing Care: PRTF Admission Criteria The family situation and functioning levels are such that the child/adolescent cannot currently remain in the home environment and receive community-based treatment Yes No 17
18 Don t assume that if a patient relapses (substance abuse) after treatment at a lower level of care that PRTF is needed. Managing Care: PRTF Admission Criteria Relapse is an expected part of the recovery process! 18
19 Managing Care: PRTF Admission Criteria (Substance Abuse) Lapse vs. Relapse LAPSE RELAPSE Impulsive Short Duration They feel guilty Small amount of use Relatively low consequences They want to stop using Planned Long period of use High defensiveness Large amount of use Relatively high consequences They aren t sure if they want to stop using 19
20 The following questions should be asked: What precipitated this admission? What other treatment episodes has this patient had? What levels of care? What worked? What needs to be put in place now? Is the patient motivated for change? Is the family /care givers supportive? If not, why not? What can be done to improve this support? What symptoms are they exhibiting that meet criteria for this level of care? PRTF Admission Criteria Key Questions 20
21 Areas to Focus On The child/adolescent has current or past behaviors that indicate the need for PRTF as evidenced by suicidal or homicidal ideation, physical aggression toward others, self-injurious behavior, seriously risky behavior (running away, sexual aggression, serial unprotected sex with multiple partners, or substance use). For each authorization, this admission criteria must be met and the treatment plan continually evaluated to determine efficacy of the treatment plan, overall safety of the patient, and appropriateness of this level of care! 21
22 All of the following must be met: Managing Care: PRTF Continued Stay Criteria The child/adolescent's condition continues to meet admission criteria at this level of care. Yes No 22
23 All of the following must be met: Managing Care: PRTF Continued Stay Criteria The child/adolescent s treatment does not require a more intensive level of care, and no less intensive level of care would be appropriate Yes No 23
24 All of the following must be met: Managing Care: PRTF Continued Stay Criteria Treatment planning is individualized and appropriate to the recipient s changing condition with realistic and specific goals and objectives stated. Treatment planning should include active family or other support systems involvement, along with social, occupational and interpersonal assessment unless contraindicated. The expected benefits from all relevant treatment modalities are documented. The treatment plan has been implemented and updated, with consideration of all applicable and appropriate treatment modalities. Yes No 24
25 All of the following must be met: Managing Care: PRTF Continued Stay Criteria All services and treatment are carefully structured to achieve optimum results in the most time efficient manner possible consistent with sound clinical practice. Yes No 25
26 All of the following must be met: Managing Care: PRTF Continued Stay Criteria If treatment progress is not evident, then there is documentation of treatment plan adjustments to address such lack of progress Yes No 26
27 All of the following must be met: Managing Care: PRTF Continued Stay Criteria Care is rendered in a clinically appropriate manner and focused on the child/adolescent s behavioral and functional outcomes Yes No 27
28 All of the following must be met: Managing Care: PRTF Continued Stay Criteria An individualized discharge plan has been developed which includes specific realistic, objective and measurable discharge criteria and plans for appropriate follow-up care. A timeline for expected implementation and completion is in place but discharge criteria have not yet been met. Yes No 28
29 All of the following must be met: Managing Care: PRTF Continued Stay Criteria Child/adolescent is actively participating in treatment to the extent possible consistent with his/her condition, or there are active efforts being made that can reasonably be expected to lead to the child/adolescent s engagement in treatment. Yes No 29
30 All of the following must be met: Managing Care: PRTF Continued Stay Criteria Unless contraindicated, family, guardian, and/or custodian is actively involved in the treatment as required by the treatment plan, or there are active efforts being made and documented to involve them. Yes No 30
31 All of the following must be met: Managing Care: PRTF Continued Stay Criteria When medically necessary, appropriate psychopharmacological intervention has been prescribed and/or evaluated. Yes No 31
32 All of the following must be met: Managing Care: PRTF Continued Stay Criteria There is documented active discharge planning from the beginning of treatment Yes No 32
33 All of the following must be met: Managing Care: PRTF Continued Stay Criteria There is a documented active attempt at coordination of care with relevant outpatient providers when appropriate Yes No 33
34 Managing Care: PRTF Continued Stay Criteria Children/adolescents have difficulty maintaining treatment gains if the family/supports haven t done their work too! Healthcare Providers Family/Supports Child/Adolescent 34
35 Managing Care: PRTF Continued Stay Criteria If treatment progress is not evident, then is there documentation of treatment plan adjustments to address such lack of progress (i.e.. Is the family/support system involved? If not why not? Have attempts to engage them been made? What happened? What now?) An individualized discharge plan has been developed with includes specific realistic, objective and measurable discharge criteria and plans for appropriate follow-up care. A timeline for expected implementation and completion is in place but discharge criteria have not yet been met. DISCHARGE PLANNING is part of treatment planning, not a discreet activity 35
36 PRTF Understanding Discharge The consumer discharge date, and discharge plan are crucial elements in mapping out the care plan Reviewers should view the discharge plan as the end goal of treatment and evaluate whether the level of care prescribed is furthering the discharge goal according to the timeline What is the estimated discharge date and plan? 36
37 PRTF: Discharge Criteria BOTH of the following must be met for Discharge: The child or adolescent can be safely treated at an alternative level of care An individualized discharge plan with appropriate, realistic and timely follow-up care is in place 37
38 PRTF Understanding Discharge In addition at least one of the following must also be met: The treatment plan goals and objectives have been substantially met or a safe, continuing care program has been put in place at an alternate level of care. Admission criteria is no longer met for this level of care and the patient can safely be treated in a less restrictive, intense environment. The support system is competent but non-participatory in treatment or in following the program rules, to such a degree that treatment has been rendered ineffective or unsafe. Consent for treatment is withdrawn, and the child/adolescent, parent, or guardian has the capacity to make an informed decision AND the patient does not meet criteria for inpatient admission. The child or adolescent is not making progress toward treatment goals despite persistent efforts to engage him or her, and there is no reasonable expectation of progress at this level of care; nor is the level of care required to maintain the current level of function. 38
39 Question and Answer Session Presented by: Lynnette Gordon, LPC, LCAS UM director Eastpointe LME/MCO
Inpatient Behavioral Health and Inpatient Substance Abuse Treatment: Aligning Care Efficiencies with Effective Treatment
Inpatient Behavioral Health and Inpatient Substance Abuse Treatment: Aligning Care Efficiencies with Effective Treatment BHM Healthcare Solutions 2013 1 Presentation Objectives Attendees will have a thorough
More informationPsychiatric Rehabilitation Clinical Coverage Policy No: 8D-1 Treatment Facilities Revised Date: August 1, 2012. Table of Contents
Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 2.0 Eligible Recipients... 1 2.1 Provisions... 1 2.2 EPSDT Special Provision: Exception to Policy Limitations for Recipients
More informationOUTPATIENT DAY SERVICES
OUTPATIENT DAY SERVICES Intensive Outpatient Programs (IOP) Intensive Outpatient Programs (IOP) provide time limited, multidisciplinary, multimodal structured treatment in an outpatient setting. Such programs
More informationTreatment Facilities Amended Date: October 1, 2015. Table of Contents
Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1 General... 1 2.1.2 Specific... 1 2.2 Special
More informationClinical Criteria 4.201 Inpatient Medical Withdrawal Management 4.201 Substance Use Inpatient Withdrawal Management (Adults and Adolescents)
4.201 Inpatient Medical Withdrawal Management 4.201 Substance Use Inpatient Withdrawal Management (Adults and Adolescents) Description of Services: Inpatient withdrawal management is comprised of services
More information8.301 Residential Treatment Services (RTS) Eating Disorders (Adult and Adolescent)
8.30 RESIDENTIAL TREATMENT CENTER SERVICES 8.301 Residential Treatment Services (RTS) Eating Disorders (Adult and Adolescent) Description of Services: Residential Treatment Services are provided to individuals
More informationHow To Know If You Can Get Help For An Addiction
2014 FLORIDA SUBSTANCE ABUSE LEVEL OF CARE CLINICAL CRITERIA SUBSTANCE ABUSE LEVEL OF CARE CLINICAL CRITERIA Overview Psychcare strives to provide quality care in the least restrictive environment. An
More information4.401 Substance Use Partial Hospitalization Program (Adults and Adolescents)
4.40 STRUCTURED DAY TREATMENT SERVICES 4.401 Substance Use Partial Hospitalization Program (Adults and Adolescents) Description of Services: Substance use partial hospitalization is a nonresidential treatment
More informationINPATIENT SERVICES. Inpatient Mental Health Services (Adult/Child/Adolescent)
INPATIENT SERVICES Inpatient Mental Health Services (Adult/Child/Adolescent) Acute Inpatient Mental Health Services represent the most intensive level of psychiatric care and is delivered in a licensed
More informationAppendix D. Behavioral Health Partnership. Adolescent/Adult Substance Abuse Guidelines
Appendix D Behavioral Health Partnership Adolescent/Adult Substance Abuse Guidelines Handbook for Providers 92 ASAM CRITERIA The CT BHP utilizes the ASAM PPC-2R criteria for rendering decisions regarding
More informationIntensive Residential Treatment Services -IRTS. Program Description
Intensive Residential Treatment Services -IRTS Program Description A highly structured non-hospital based treatment setting that brings comprehensive and specialized diagnostic and treatment services to
More informationADVANCED BEHAVIORAL HEALTH, INC. Clinical Level of Care Guidelines - 2015
The Clinical Level of Care Guidelines contained on the following pages have been developed as a guide to assist care managers, physicians and providers in making medical necessity decisions about the least
More informationInstructions for Funding Authorization/Reauthorization Process. Residential Alcohol and Other Drug Treatment Programs
Instructions for Funding Authorization/Reauthorization Process Clinician Instructions: Residential Alcohol and Other Drug Treatment Programs For initial authorization or authorization of continued stay,
More informationOptum By United Behavioral Health. 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines
Optum By United Behavioral Health 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines (TBOS) Therapeutic behavioral on-site services are intended to prevent members under the
More informationOptum By United Behavioral Health. 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines
Optum By United Behavioral Health 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines Statewide Inpatient Psychiatric Program Services (SIPP) Statewide Inpatient Psychiatric
More informationLEVEL III.5 SA: SHORT TERM RESIDENTIAL - Adult (DUAL DIAGNOSIS CAPABLE)
LEVEL III.5 SA: SHT TERM RESIDENTIAL - Adult (DUAL DIAGNOSIS CAPABLE) Definition The following is based on the Adult Criteria of the Patient Placement Criteria for the Treatment of Substance-Related Disorders
More information8.401 Eating Disorder Partial Hospitalization Program (Adult and Adolescent)
8.40 STRUCTURED DAY TREATMENT SERVICES 8.401 Eating Disorder Partial Hospitalization Program (Adult and Adolescent) Description of Services: Eating Disorder partial hospitalization is a nonresidential
More informationRESIDENTIAL TREATMENT CENTER (RTC)
RESIDENTIAL TREATMENT CENTER (RTC) Service Description Residential Treatment Center (RTC) IOS provides 24-hour staff supervised all-inclusive clinical services in a community-based therapeutic setting
More information8.201 Acute Inpatient Eating Disorder (Adult and Adolescent)
8.20 INPATIENT SERVICES 8.201 Acute Inpatient Eating Disorder (Adult and Adolescent) Description of Services: Acute inpatient eating disorder treatment represents the most intensive level of psychiatric
More informationIntensive Customized Care Coordination Transaction
Transaction Code Detail Code Mod 1 Mod 2 Mod 3 Mod 4 Rate Code Communitybased wraparound Community-based wrap-around services H2022 HK services, monthly Unit Value 1 month Maximum Daily Units Initial 12
More informationOptum By United Behavioral Health. 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines
Optum By United Behavioral Health 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines Therapeutic group care services are community-based, psychiatric residential treatment
More informationMEDICAL POLICY No. 91607-R1 MENTAL HEALTH RESIDENTIAL TREATMENT: CHILD AND ADOLESCENT
Summary of Changes MEDICAL POLICY MENTAL HEALTH RESIDENTIAL TREATMENT: CHILD ADOLESCENT Effective Date: June 4, 2015 Review Dates: 5/14, 5/15 Date Of Origin: May 14, 2014 Status: Current Clarifications:
More informationMedical Necessity Criteria
Medical Necessity Criteria 2015 Updated 03/04/2015 Appendix B Medical Necessity Criteria Purpose: In order to promote consistent utilization management decisions, all utilization and care management staff
More informationWORKERS COMPENSATION PROTOCOLS WHEN PRIMARY INJURY IS PSYCHIATRIC/PSYCHOLOGICAL
WORKERS COMPENSATION PROTOCOLS WHEN PRIMARY INJURY IS PSYCHIATRIC/PSYCHOLOGICAL General Guidelines for Treatment of Compensable Injuries Patient must have a diagnosed mental illness as defined by DSM-5
More informationCIGNA MEDICAL NECESSITY CRITERIA
CIGNA MEDICAL NECESSITY CRITERIA for Treatment of Behavioral Health and Substance Use Disorders 839233 a 11/12 Offered by: Connecticut General Life Insurance Company or Cigna Health and Life Insurance
More informationComprehensive Behavioral Care, Inc. Level of Care Guidelines Substance Abuse Children/Adolescents
Medical Necessity In considering the appropriateness of any level of care, the four basic elements of Medical Necessity should be met: 1. A diagnosis as defined by standard diagnosis nomenclatures (DSM
More informationSUBSTANCE USE DISORDER SOCIAL DETOXIFICATION SERVICES [ASAM LEVEL III.2-D]
SUBSTANCE USE DISORDER SOCIAL DETOXIFICATION SERVICES [ASAM LEVEL III.2-D] I. Definitions: Detoxification is the process of interrupting the momentum of compulsive drug and/or alcohol use in an individual
More informationOptum By United Behavioral Health. 2015 Mississippi Coordinated Access Network (CAN) Medicaid Level of Care Guidelines
Optum By United Behavioral Health 2015 Mississippi Coordinated Access Network (CAN) Medicaid Level of Care Guidelines is a behavioral intervention program, provided in the context of a therapeutic milieu,
More informationA Review of the Beacon Health Options Clinical Case Management
Clinical 3.50 CASE MANAGEMENT 3.504 Intensive Case Management (Child/Adolescent) Description of Services: Intensive Case Management provides for a single point of coordination/accountability in managing
More informationMEDICAL POLICY No. 91608-R1 MENTAL HEALTH RESIDENTIAL TREATMENT: ADULT
MENTAL HEALTH RESIDENTIAL TREATMENT: ADULT Effective Date: June 4, 2015 Review Dates: 5/14, 5/15 Date Of Origin: May 12, 2014 Status: Current Summary of Changes Clarifications: Pg 4, Description, updated
More informationLEVEL I SA: OUTPATIENT INDIVIDUAL THERAPY - Adult
LEVEL I SA: OUTPATIENT INDIVIDUAL THERAPY - Adult Definition The following is based on the Adult Criteria of the Patient Placement Criteria for the Treatment of Substance-Related Disorders of the American
More informationLEVEL II.1 SA: INTENSIVE OUTPATIENT - Adult
LEVEL II.1 SA: INTENSIVE OUTPATIENT - Adult Definition The following is based on the Adult Criteria of the Patient Placement Criteria for the Treatment of Substance- Related Disorders of the American Society
More informationINTENSIVE IN HOME SERVICES FOR THE INTELLECTUALLY AND/OR DEVELOPMENTALLY DISABLED (I/DD) YOUTH
CSOC Service Guidelines Clinical Criteria INTENSIVE IN HOME SERVICES FOR THE INTELLECTUALLY AND/OR DEVELOPMENTALLY DISABLED (I/DD) YOUTH Definition Intensive In-Home Services means an array of rehabilitation
More informationPsychiatric Residential Treatment Facility Referral
Psychiatric Residential Treatment Facility Referral Date of referral: Psychiatric Residential Treatment Facility (PRTF) Referral Information Referral contact: Phone number: Referring facility/agency: Fax
More informationAppendix B NMMCP Covered Services and Exceptions
Acute Inpatient Hospitalization MH - Adult Definition An Acute Inpatient program is designed to provide medically necessary, intensive assessment, psychiatric treatment and support to individuals with
More informationTREATMENT MODALITIES. May, 2013
TREATMENT MODALITIES May, 2013 Treatment Modalities New York State Office of Alcoholism and Substance Abuse Services (NYS OASAS) regulates the addiction treatment modalities offered in New York State.
More informationAN INTRODUCTION ASAM
AN INTRODUCTION ASAM 2013 Ray Caesar LPC, LADC-MH Director of Addiction Specialty Programs ODMHSAS (405)522-3870 rcaesar@odmhsas.org AMERICAN SOCIETY OF ADDICTON MEDICINE ASAM ASAM is a professional organization
More informationSubacute Inpatient MH - Adult
Subacute Inpatient MH - Adult Definition Subacute Inpatient hospital psychiatric services are medically necessary short-term psychiatric services provided to a client with a primary psychiatric diagnosis
More informationState of Illinois. Department of Human Services/Division of Mental Health. Medical Necessity Criteria and Guidance Manual
Introduction Consistent with Rule 132, DHS/DMH is providing enhanced Medical Necessity Guidance for the following Rule 132 services: Assertive Community Treatment (ACT) adult only Community Support Team
More informationThe Department of Children and Families Substance Abuse Program
The Department of Children and Families Substance Abuse Program Florida Supplement To the American Society of Addiction Medicine Patient Placement Criteria For the Treatment of Substance-Related Disorders
More informationIntensive Outpatient Psychotherapy - Adult
Intensive Outpatient Psychotherapy - Adult Definition Intensive Outpatient Psychotherapy services provide group based, non-residential, intensive, structured interventions consisting primarily of counseling
More informationBehavioral Health Medical Necessity Criteria
Behavioral Health Medical Necessity Criteria Revised: 7/14/05 2 nd Revision: 9/14/06 3 rd Revision: 8/23/07 4 th Revision: 8/28/08; 11/20/08 5 th Revision: 8/27/09 Anthem Blue Cross and Blue Shield 2 Gannett
More informationother caregivers. A beneficiary may receive one diagnostic assessment per year without any additional authorization.
4.b.(8) Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services (continued) Attachment 3.1-A.1 Page 7c.2 (a) Psychotherapy Services: For the complete description of the service providers,
More information1. The youth is between the ages of 12 and 17.
Clinical MULTISYSTEMIC THERAPY (MST) Definition Multisystemic therapy (MST) is an intensive family and community-based treatment that addresses multiple aspects of serious antisocial behavior in adolescents.
More informationLevel of Care Criteria Psychiatric Criteria
LEVEL OF CARE AND TREATMENT CRITERIA Level of Care Criteria Psychiatric Criteria Adult Half Day Partial Hospital Treatment Adult Psychiatric Home Care Child and Adolescent Half Day Partial Hospital Treatment
More informationProfessional Treatment Services in Facility-Based Crisis Program Children and Adolescents
Professional Treatment Services in Facility-Based Crisis Program Children and Adolescents Medicaid and North Carolina Health Choice (NCHC) Billable Service WORKING DRAFT Revision Date: September 11, 2014
More informationTHE OFFICE OF SUBSTANCE ABUSE SERVICES REQUIREMENTS FOR THE PROVISION OF RESIDENTIAL DETOXIFICATION SERVICES BY PROVIDERS FUNDED WITH DBHDS RESOURCES
THE OFFICE OF SUBSTANCE ABUSE SERVICES REQUIREMENTS FOR THE PROVISION OF RESIDENTIAL DETOXIFICATION SERVICES BY PROVIDERS FUNDED WITH DBHDS RESOURCES PURPOSE: The goal of this document is to describe the
More informationThe purpose of this policy is to describe the criteria used by BHP in medical necessity determinations for inpatient CH treatment services.
Page 1 of 5 Category: Code: Subject: Purpose: Policy: Utilization Management Inpatient (IP) Chemical Health (CH) Level of Care Guidelines The purpose of this policy is to describe the criteria used by
More informationDurham SOC Care Review LEVELS OF RESIDENTIAL CARE
The following is a description of the levels of residential care available to the children of North Carolina. These services can be provided in a variety of locations from urban to rural, from facility
More informationOptum By United Behavioral Health. 2015 Mississippi Coordinated Access Network (CAN) Medicaid Level of Care Guidelines
Optum By United Behavioral Health 2015 Mississippi Coordinated Access Network (CAN) Medicaid Level of Care Guidelines Assertive Community Treatment is a multi-disciplinary, selfcontained clinical team
More informationASAM 101: How to complete the ASAM Placement Form
ASAM 101: How to complete the ASAM Placement Form What is the ASAM? The ASAM Placement Form is a document required by contract The ASAM Form is an ASSESSMENT tool as well as a PLACEMENT tool It seeks to
More informationDay Treatment Mental Health Adult
Day Treatment Mental Health Adult Definition Day Treatment provides a community based, coordinated set of individualized treatment services to individuals with psychiatric disorders who are not able to
More informationMEDICAL ASSOCIATES HEALTH PLANS HEALTH CARE SERVICES POLICY AND PROCEDURE MANUAL POLICY NUMBER: PP 27
POLICY TITLE: RESIDENTIAL TREATMENT CRITERIA POLICY STATEMENT: Provide consistent criteria when determining coverage for Residential Mental Health and Substance Abuse Treatment. NOTE: This policy applies
More informationPsychosocial Rehabilitation Program Services
Psychosocial Rehabilitation Program Services 2013 Overview Objectives Definitions What it is not What it is Who can provide What to focus on Populations of Service Documentation Requirements 2 Objectives
More informationPerformance Standards
Performance Standards Outpatient Performance Standards are intended to provide a foundation and serve as a tool to promote continuous quality improvement and progression toward best practice performances,
More informationHow To Know If You Should Be Treated
Comprehensive ehavioral Care, Inc. delivery system that does not include sufficient alternatives to a particular LOC and a particular patient. Therefore, CompCare considers at least the following factors
More information907 KAR 9:005. Level I and II psychiatric residential treatment facility service and coverage policies.
907 KAR 9:005. Level I and II psychiatric residential treatment facility service and coverage policies. RELATES TO: KRS 205.520, 216B.450, 216B.455, 216B.459 STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1),
More informationOptum By United Behavioral Health. 2015 New Jersey Managed Long-Term Services and Support (MLTSS) Medicaid Level of Care Guidelines
Optum By United Behavioral Health 2015 New Jersey Managed Long-Term Services and Support (MLTSS) Medicaid Level of Care Guidelines (AMHR) AMHR provides services in/by a licensed community residence. Services
More informationBehavioral Health Review Mental Health
Behavioral Health Review Mental Health Name: Age: Insured ID: County: PH Plan: High need: Does the consumer have a history of D/A service: Has the consumer signed an ROI: Level of care Type of review:
More informationWCHO PIHP/CA POLICY for the LIVINGSTON- WASHTENAW COORDINATING AGENCY Department: Coordinating Agency Author: Marci Scalera Approval Date 4/17/12
WCHO PIHP/CA POLICY for the LIVINGSTON- WASHTENAW COORDINATING AGENCY Department: Coordinating Agency Author: Marci Scalera Approval Date 4/17/12 Policy and Procedure Residential Treatment Services Policy
More informationPartial Hospitalization - MH - Adult (Managed Medicaid only Service)
Partial Hospitalization - MH - Adult (Managed Medicaid only Service) Definition Partial hospitalization is a nonresidential treatment program that is hospital-based. The program provides diagnostic and
More informationNew York State Office of Alcoholism & Substance Abuse Services Addiction Services for Prevention, Treatment, Recovery
New York State Office of Alcoholism & Substance Abuse Services Addiction Services for Prevention, Treatment, Recovery USING THE 48 HOUR OBSERVATION BED USING THE 48 HOUR OBSERVATION BED Detoxification
More informationDEPARTMENT OF SERVICES FOR CHILDREN, YOUTH AND THEIR FAMILIES DIVISION OF CHILD MENTAL HEALTH SERVICES PROGRAM DESCRIPTIONS
DEPARTMENT OF SERVICES FOR CHILDREN, YOUTH AND THEIR FAMILIES DIVISION OF CHILD MENTAL HEALTH SERVICES PROGRAM DESCRIPTIONS OVERVIEW The Division of Child Mental Health Services provides both mental health
More informationAMERICAN SOCIETY OF ADDICTION MEDICINE Patient Placement Criteria for the Treatment of Substance-Related Disorders (Second Edition-Revised) 2001
AMERICAN SOCIETY OF ADDICTION MEDICINE Patient Placement Criteria for the Treatment of Substance-Related Disorders (Second Edition-Revised) 2001 LME Utilization Review Training LEARNING GOALS: By the end
More informationAmerican Society of Addiction Medicine
American Society of Addiction Medicine Public Policy Statement on Treatment for Alcohol and Other Drug Addiction 1 I. General Definitions of Addiction Treatment Addiction Treatment is the use of any planned,
More informationTRANSITIONAL RESIDENTIAL TREATMENT PROGRAM Session Law 2007-323 House Bill 1473, Section 10.49(i)
REPORT TO THE THE JOINT LEGISLATIVE OVERSIGHT COMMITTEE ON MENTAL HEALTH, DEVELOPMENTAL DISABILITIES AND SUBSTANCE ABUSE SERVICES TRANSITIONAL RESIDENTIAL TREATMENT PROGRAM Session Law 2007-323 House Bill
More informationINTELLECTUAL/DEVELOPMENTAL DISABILITY GROUP HOME
INTELLECTUAL/DEVELOPMENTAL DISABILITY GROUP HOME IDD Group Home - Level 1 (IDD GH-1) Service Description Moderate Level IDD Group Homes (GH Level 1-IDD) are designed for youth up to the age of 21 who are
More informationCare Management Council submission date: August 2013. Contact Information
Clinical Practice Approval Form Clinical Practice Title: Acute use of Buprenorphine for the Treatment of Opioid Dependence and Detoxification Type of Review: New Clinical Practice Revisions of Existing
More informationProgram of Assertive Community Services (PACT)
Program of Assertive Community Services (PACT) Service/Program Definition Program of Assertive Community Services (PACT) entails the provision of an array of services delivered by a community-based, mobile,
More informationBehavioral Health Medical Necessity Criteria
Behavioral Health Medical Necessity Criteria Effective January 1, 2011 Revised and approved on 8/19/2010 The Office of Medical Policy and Technological Assessment (OMPTA) has developed policies that serve
More informationTN No: 09-024 Supersedes Approval Date:01-27-10 Effective Date: 10/01/09 TN No: 08-011
Page 15a.2 (iii) Community Support - (adults) (CS) North Carolina is revising the State Plan to facilitate phase out of the Community Support - Adults service, which will end effective July 1, 2010. Beginning
More informationCRITERIA CHECKLIST. Serious Mental Illness (SMI)
Serious Mental Illness (SMI) SMI determination is based on the age of the individual, functional impairment, duration of the disorder and the diagnoses. Adults must meet all of the following five criteria:
More informationAlcohol and Drug Abuse Treatment Centers
Division of State Operated Healthcare Facilities Alcohol and Drug Abuse Treatment Centers Jenny Wood Interim ADATC Team Leader HHS LOC Mental Health Subcommittee February 24, 2014 ADATC Locations R.J.
More informationThe goal of Utilization Management (UM) is to ensure that all services that are authorized meet the Departments definition of medical necessity.
IV. Utilization Management and Care Management The primary vision that guided the development of the CT BHP was to develop an integrated public behavioral health service system that offers enhanced access
More informationSuicide Screening Tool for School Counselors
Suicide Screening Tool for School Counselors I. Risk Factors Check all that apply History of prior suicide attempts Self-injurious behaviors (past or present) Feelings of hopelessness Impulsivity Anxiety
More informationSTATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES DIVISION OF MENTAL HEALTH AND ADDICTION SERVICES. (Pursuant to N.J.S.A. 30:4-27.
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES DIVISION OF MENTAL HEALTH AND ADDICTION SERVICES SCREENING DOCUMENT FOR ADULTS (Pursuant to N.J.S.A. 30:4-27.1 et seq) to Instructions New Jersey Court
More informationOptum By United Behavioral Health. 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines
Optum By United Behavioral Health 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines (PSR) services combine daily medication use, independent living and social skills training,
More informationRULES OF THE TENNESSEE DEPARTMENT OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES
RULES OF THE TENNESSEE DEPARTMENT OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES CHAPTER 0940-05-47 MINIMUM PROGRAM REQUIREMENTS FOR ALCOHOL AND DRUG OUTPATIENT DETOXIFICATION TREATMENT FACILITIES TABLE
More informationDepartment of Mental Health and Addiction Services 17a-453a-1 2
17a-453a-1 2 DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES General Assistance Behavioral Health Program The Regulations of Connecticut State Agencies are amended by adding sections 17a-453a-1 to 17a-453a-19,
More informationCommunity, Schools, Cyberspace and Peers. Community Mental Health Centers (Managing Risks and Challenges) (Initial Identification)
Community Mental Health Centers (Managing Risks and Challenges) Inpatient Hospitalization (New Hampshire Hospital) (Assessment, Treatment Planning/Discharge) Community, Schools, Cyberspace and Peers (Initial
More informationTexas Foster Care Outpatient Treatment Requests (OTRs)
Texas Foster Care Outpatient Treatment Requests (OTRs) Recovery Are the interventions built on client strengths and intended to reduce or eliminate the impact of the mental health condition so the client
More informationRESIDENTIAL TREATMENT DEFINITIONS FOR CHILDREN AND ADOLESCENTS
DEFINITIONS FOR CHILDREN AND ADOLESCENTS For Health Choice, only Levels II, III, and IV apply. See and Utilization Review/Continuation for program specifics. LEVEL I Therapeutic Relationship Therapeutic
More informationBehavioral Health Medical Necessity Criteria
Behavioral Health Medical Necessity Criteria Effective January 1, 2013 Revised and approved on 8/09/2012 Anthem Blue Cross 21555 Oxnard St. Woodland Hills, CA 91365 Toll free: 1-800-274-7767 The Office
More informationMedical Necessity Criteria Guidelines
Medical Necessity Criteria Guidelines Version 1.3 Effective Date: January 1, 2015 Updated: November 12, 2014 Medical Necessity Criteria Guidelines 2007-2015 Magellan Health, Inc. Table of Contents 2007-2015
More informationOptum By United Behavioral Health. 2015 KanCare Medicaid Level of Care Guidelines
Optum By United Behavioral Health 2015 KanCare Medicaid Level of Care Guidelines (PRTF) A sub-acute facility-based program which delivers 24-hour/7-day assessment and diagnostic services, and active behavioral
More informationWhat is CCS? Eligibility
What is CCS? Department of Health Services Division of Mental Health and Substance Abuse Services Bureau of Prevention, Treatment and Recovery Services Comprehensive Community Services (CCS) Comprehensive
More informationHow To Care For A Member Of A Psychiatric Rehab Facility
2015 Level of Care Guidelines SH & ESH Supported Housing and Enhanced Supported Housing Psychiatric Rehabilitation services are defined by the Bureau of TennCare per the Contractor Risk Agreement (CRA).
More informationCare Management Organization (CMO)- ModeratenifiedUnified Care Management: High
Clinical Care Management Organization/- Moderate Care Management Organization (CMO)- ModeratenifiedUnified Care Management: High Program Description Care Management Organizations (CMO) are independent,
More informationLEVEL OF CARE GUIDELINES
LEVEL OF CARE GUIDELINES October 2012 Key Code: Throughout this document highlighting occurs to reflect direct language of either the State regulations or approved service definitions which were in effect
More informationFlorida Data as of July 2003. Mental Health and Substance Abuse Services in Medicaid and SCHIP in Florida
Mental Health and Substance Abuse Services in Medicaid and SCHIP in Florida As of July 2003 2,441,266 people were covered under Florida's Medicaid and SCHIP programs. There were 2,113,820 enrolled in the
More informationBehavioral Health Covered Services
Behavioral Health Covered Services Inpatient Services - 24-hour services, delivered in a licensed hospital setting, that provide clinical intervention for mental health or substance use diagnoses, or both.
More informationJACKSON RECOVERY CENTERS Initial Substance Abuse Assessment Form. Substance used: Method: Age started: Last used: Frequency/progression of use:
JACKSON RECOVERY CENTERS Initial Substance Abuse Assessment Form PRESENTING PROBLEM DRUGS OF CHOICE Substance used: Method: Age started: Last used: Frequency/progression of use: Indicators of Addiction:
More informationINSTRUCTIONS AND PROTOCOLS FOR THE IMPLEMENTATION OF CASE MANAGEMENT SERVICES FOR INDIVIDUALS AND FAMILIES WITH SUBSTANCE USE DISORDERS
201 Mulholland Bay City, MI 48708 P 989-497-1344 F 989-497-1348 www.riverhaven-ca.org Title: Case Management Protocol Original Date: March 30, 2009 Latest Revision Date: August 6, 2013 Approval/Release
More informationPublished Date: January 1, 2016 Table of Contents
NC Division of Mental Health, Facility-Based Developmental Disabilities & Crisis Service for Children Substance Abuse Services and Adolescents Published Date: January 1, 2016 Table of Contents Description
More informationMay 21, 2015 Joint Committee on Finance Paper #352
Legislative Fiscal Bureau One East Main, Suite 301 Madison, WI 53703 (608) 266-3847 Fax: (608) 267-6873 Email: fiscal.bureau@legis.wisconsin.gov Website: http://legis.wisconsin.gov/lfb May 21, 2015 Joint
More informationTelemedicine services. Crisis intervcntion response services, except
Approved: MAY 2 4 2010 ATTACHMENT 3.1 -A Page 54j 4. Consultation with relatives, guardians, friends, employers, treatment providers, and other significant people, in order to change situations and allow
More informationLocation of Service: 707 Broadway NE # 500, Albuquerque NM 87102
Department: Service Name: Type of Service: Out Patient Services NMS Outpatient Services Mental Health Out Patient Services Location of Service: 707 Broadway NE # 500, Albuquerque NM 87102 Description of
More informationTexas Resilience and Recovery. Utilization Management Guidelines: Adult Mental Health Services
Texas Resilience and Recovery Utilization Management Guidelines: Adult Mental Health Services Effective September 2015 Introduction Texas Resiliency and Recovery, or TRR is a term to describe the service
More informationPhoenix House. Outpatient Treatment Services for Adults in Los Angeles and Orange Counties
Phoenix House Outpatient Treatment Services for Adults in Los Angeles and Orange Counties Phoenix House s outpatient programs offer comprehensive and professional clinical services that include intervention,
More information