Inpatient Behavioral Health and Inpatient Substance Abuse Treatment: Aligning Care Efficiencies with Effective Treatment
|
|
- Leona Lucas
- 8 years ago
- Views:
Transcription
1 Inpatient Behavioral Health and Inpatient Substance Abuse Treatment: Aligning Care Efficiencies with Effective Treatment BHM Healthcare Solutions
2 Presentation Objectives Attendees will have a thorough understanding of Inpatient Behavioral Health and Inpatient Substance Abuse Treatment (IP) from an authorization perspective Attendees will gain an understanding of the importance of Medical Necessity Criteria as it applies to Inpatient Behavioral Health and Inpatient Substance Abuse Treatment Attendees will learn key questions to ask through the authorization process BHM Healthcare Solutions
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 or infirmity Treatment is expected to improve the condition or levels of functions in relationship to the presenting diagnosis BHM Healthcare Solutions
4 Understanding Medical Necessity Criteria (MNC) According to a presentation by NC Department of Health and Human Services (Division of Medical Assistance) Medical Necessity Essential and consistent with nationally acceptable standard of practice Individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the recipient s needs Can be safely furnished, and no equally and more conservative or less costly treatment is available statewide Is furnished in a manner not primarily intended for the convenience of the recipient, the recipient s caretaker, or the provider BHM Healthcare Solutions
5 Understanding Inpatient Behavioral Health Services Inpatient Behavioral Health services provide hospital treatment in a hospital setting 24 hours per day. Supportive nursing and medical care are provided under the supervision of a psychiatrist or a physician. This service is designed to provide continuous treatment for beneficiaries with acute psychiatric problems and/or acute substance abuse problems. BHM Healthcare Solutions
6 They are appropriate for members whose acute biomedical and emotional, behavioral or cognitive problems are so severe that they require primary medical and nursing care. Understanding Inpatient Behavioral Health Services BHM Healthcare Solutions
7 Understanding Inpatient Behavioral Health Services This level of care (LOC) is intended to accomplish the following: Attain a level of functioning (stabilization of psychiatric symptoms and/or the establishment of abstinence) sufficient to allow for mental health or substance abuse treatment in a less restrictive environment Provide the patient and their parents/support system the opportunity to become informed participants through the course of hospitalization and aftercare Ensure linkage to lower levels of care (eventually community based) BHM Healthcare Solutions
8 Understanding Inpatient Behavioral Health Services This intensive LOC includes, but is not limited to, the following face-to-face and structured interventions as clinically indicated: Medication management Individual and family psychotherapy Group therapy Dual diagnosis treatment for psychiatric and substance abuse disorders Developing and Implementing a step down behavioral support plan with the patient and the patient s caregivers BHM Healthcare Solutions
9 All criteria must be met for admission: Managing Care: IP BH Services Admission Criteria (Child and Adolescent) A. The beneficiary shall meet criteria for one or more of the following DSM-IV Diagnoses: 1. Beneficiary is presently danger to self (e.g., engages in self-injurious behavior, has a significant potential, or is acutely manic). This usually would be indicated by one of the following: a. Beneficiary has made a suicide attempt or serious gesture (e.g. Overdose, hanging, jumping from or placing self in front of moving vehicle, self-inflicted gunshot wound), or is threatening same with likelihood of acting on the threat, and there is an absence of supervision or structure to prevent suicide of the beneficiary who has made an attempt, serious gesture or threat. b. Beneficiary manifests a significant depression, including current contemplation of suicide or suicidal ideation, and there is an absence of supervision or structure to prevent suicide. c. Beneficiary has a history of affective disorder: I. with mood which has fluctuated to the manic phase, OR II. has destabilized due to stressors or non-compliance with treatment. BHM Healthcare Solutions
10 Managing Care: IP BH Services Admission Criteria (Child and Adolescent) All criteria must be met for admission: d. Beneficiary is exhibiting self-injurious (cutting on self, burning self) or is threatening same with likelihood of acting on the threat; OR 2. Beneficiary engages in actively violent, aggressive or disruptive behavior or beneficiary exhibits homicidal ideation or other symptoms which indicate the beneficiary is a probable danger to others. This usually would be indicated by one of the following: a. Beneficiary whose evaluation and treatment cannot be carried out safely or effectively in other settings due to impulsivity, impaired judgment, severe oppositional behavior, running away, severely disruptive behaviors at home or school, self-defeating and self endangering activities, antisocial activity, and other behaviors which may occur in the context of a dysfunctional family and may also include physical, psychological, or sexual abuse. b. Beneficiary exhibits serious aggressive, assaultive, or sadistic behavior that is harmful to others (e.g., assaults with or without weapons, provocations of fights, gross aggressive over-reactivity to minor irritants, harming animals or is threatening same with likelihood of acting on the threat. This behavior should be attributable to the beneficiary s specific DSM-IV diagnosis and can be treated only in a hospital setting; OR BHM Healthcare Solutions
11 Managing Care: IP BH Services Admission Criteria (Child and Adolescent) All criteria must be met for admission: 3. Acute onset of psychosis or severe thought disorganization or clinical deterioration in condition of chronic psychosis rendering the beneficiary unmanageable and unable to cooperate in treatment. This usually would be indicated by ONE of the following: Beneficiary has recent onset or aggravated psychotic symptoms (e.g., disorganized or illogical thinking, hallucinations, bizarre behavior, paranoia, delusions, incongruous speech, severely impaired judgment) and is resisting treatment or is in need of assessment in a safe and therapeutic setting; OR 4. Presence of medication needs, or a medical process or condition, which is life threatening (e.g., toxic drug level) or which requires the acute care setting for its treatment. This usually would be indicated by ONE of the following: a. Proposed treatments require close medical observation and monitoring to include, but not limited to, close monitoring for adverse medication effects, capacity for rapid response to adverse effects, and use of medications in clients with concomitant serious medical problems. b. Beneficiary has a severe eating disorder or substance abuse disorder, which requires 24-hour-a-day medical observation, supervision, and intervention. BHM Healthcare Solutions
12 All criteria must be met for admission: Managing Care: IP BH Services Admission Criteria (Child and Adolescent) 5. Need for medication therapy or complex diagnostic evaluation where the client s level of functioning precludes cooperation with the treatment regimen, including forced administration of medication. This usually would be indicated by ONE of the following: a. Beneficiary whose diagnosis and clinical picture is unclear and who requires 24 hour clinical observation and assessment by a multidisciplinary hospital psychiatric team to establish the diagnosis and treatment recommendations. b. Beneficiary is involved in the legal system (e.g., in a detention or training school facility) and manifests psychiatric symptoms (e.g., psychosis, depression, suicide attempts or gestures) and requires a comprehensive assessment in a hospital setting to clarify the diagnosis and treatment needs; AND B. A provider team shall certify that the beneficiary meets each of the certification of need requirements listed at 42 CFR BHM Healthcare Solutions
13 Managing Care: IP BH Services Admission Criteria (Child and Adolescent) B. A provider team shall certify that the beneficiary meets each of the certification of need requirements listed at 42 CFR To meet the federal requirement at 42 CFR , all of the following must apply: (a) Ambulatory care resources available in the community do not meet the treatment needs of the recipient. (b) Proper treatment of the recipient s psychiatric condition requires services on an inpatient basis under the direction of a physician. (c) The services can reasonably be expected to improve the recipient s condition or prevent further regression so that services will no longer be needed. BHM Healthcare Solutions
14 Areas to Focus On In NC, hospitals are required to submit the initial request for authorization within 48 hours of admission for Medicaid requests. The member must meet the clinical criteria for imminent dangerousness to self and/or others, be acutely psychotic, in need of detox, or have medication or diagnostic needs that cannot be safely treated in a lower level of care. BHM Healthcare Solutions
15 All of the following criteria must be met: Managing Care: IP Preadmission Review Criteria for Substance Abuse for Medicaid Beneficiaries (Ages 21 64) A. Any DSM-IV diagnosis of substance abuse or dependency AND ONE of the following: 1. Need for skilled observation (including instance of coma or stupor) or therapeutic milieu necessitating inpatient treatment. 2. Need for detoxification and not manageable by alternative treatment 3. Potential danger to self or others and not manageable by alternative treatment 4. Onset of, or impending, convulsions or delirium tremens or toxic psychosis 5. Presence of significant medical disorder or other disabling psychiatric disorder necessitating inpatient treatment B. This is used in combination with American Society of Addiction Medicine (ASAM) criteria when appropriate. BHM Healthcare Solutions
16 Dimensional Admission Criteria for Substance Abuse (Adult) Direct admission to a Level IV program is available for the adult who meets the instability specifications in Dimension 1 (acute intoxication and /or withdrawal) OR Dimension 2 (biomedical conditions or problems) OR Dimension 3 (emotional, behavioral or cognitive conditions). A member s problems in Dimensions 4, 5, and 6 do not need to be met. 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 BHM Healthcare Solutions
17 Dimensional Admission Criteria for Substance Abuse (Adult) DIMENSION 1: Acute Intoxication and/or Withdrawal 1. Member must be experiencing or at risk of experiencing acute withdrawal, and requires intensive medical management DIMENSION 2: Biomedical Conditions and Complications 1. Member s biomedical conditions are severe and require 24-hour medical and nursing care 2. Member s biomedical conditions are severe enough to distract from treatment at a less intensive level of care BHM Healthcare Solutions
18 Dimensional Admission Criteria for Substance Abuse (Adult) DIMENSION 3: Emotional, Behavioral or Cognitive Conditions 1. The member s status in Dimension 3 is characterized by at least one of the following: a. Dangerousness/Lethality- severe risk of harm to self or others b. Interference with Recovery Efforts- very severe-almost to overwhelming interference renders the member incapable of participating in treatment at a less intensive level of care c. Social Functioning symptoms are causing very severe, dangerous impairment and requires frequent medical monitoring d. Ability for Self Care experiencing very severe difficulties with activities of daily living e. Course of Illness history and present condition suggests that emotional, behavioral, cognitive conditions will be unstable without monitoring DIMENSION 4: Readiness to Change 1. The member s problems in this dimension do not qualify him or her for a level IV service BHM Healthcare Solutions
19 Dimensional Admission Criteria for Substance Abuse (Adult) DIMENSION 5: Relapse, Continued Use or Continued Problem Potential 1. The member s problems in this dimension do not qualify him or her for a Level IV service. DIMENSION 6: Recovery Environment 1. The member s problems in this dimension do not qualify him or her for a Level IV service. BHM Healthcare Solutions
20 Remember.. Areas to Focus On Assess the severity of symptoms and determine whether the member can safely be treated on a lower level of care. ASAM Criteria is NOT to be used solely but in conjunction with the Preadmission Review Criteria for Substance Abuse (there are 5 and the member must meet one of these). BHM Healthcare Solutions
21 Preadmission Review Criteria for Non-Substance Abuse for Medicaid Beneficiaries (ages 21-64) (Adult) The following are criteria for preadmission review for psychiatric treatment of adult non-substance abuse and all other conditions: Any DSM-IV Axis I or II diagnosis AND ONE of the following: a. Impaired reality testing (e.g., delusions, hallucinations), disordered behavior or other acute disabling symptoms not manageable by alternative treatment b. Potential danger to self or others and not manageable by alternative treatment c. Concomitant severe medical illness or substance abuse necessitating inpatient treatment d. Severely impaired social, familial, occupational or developmental functioning that cannot be effectively evaluated or treated by alternative treatment e. Failure of or inability to benefit from alternative treatment, in the presence of severe disabling psychiatric illness f. Need for skilled observation, special diagnostic or therapeutic procedures or therapeutic milieu necessitating inpatient treatment BHM Healthcare Solutions
22 Areas to Focus On Focus on the following: Why now? This may be a chronic state or something could have happened to cause the patient to decompensate suddenly. What the patient is saying or doing that requires this level of care must be documented. Give specifics What does the member s baseline level of functioning look like? Assess their support system. What previous treatment have they had? What did or did not work? What is needed for this member to improve? BHM Healthcare Solutions
23 Managing Care: IP BH Services Continued Stay Criteria All criteria must be met: A. The beneficiary has one of the following: 1. Presence of a current DSM-IV, Axis I diagnosis; OR 2. Presence of a current DSM-IV, Axis II diagnosis AND current symptoms/behaviors which are characterized by ALL of the following: a. Symptoms or behaviors are likely to respond positively to acute inpatient treatment; AND b. Symptoms or behaviors are not characteristic of patient s baseline functioning* ; AND c. Presenting problems are an acute exacerbation of dysfunctional behavior patterns, which are recurring and resistive to change. BHM Healthcare Solutions
24 All criteria must be met: Managing Care: IP BH Services Continued Stay Criteria (cont.) B. Symptoms are not due solely to intellectual disability. C. The symptoms of the beneficiary are characterized by: 1. At least one of the following: a. Endangerment of self or others; OR b. Behaviors which are grossly bizarre, disruptive, and provocative (e.g. feces smearing, disrobing, pulling out hair); OR c. Related to repetitive behavior disorders which present at least five times in a 24-hour period; OR d. Directly result in an inability to maintain age appropriate roles; AND BHM Healthcare Solutions
25 All criteria must be met: Managing Care: IP BH Services Continued Stay Criteria (cont.) 2. The symptoms of the beneficiary are characterized by a degree of intensity sufficient to require continual medical/nursing response, management, and monitoring. D. The services provided in the facility can reasonably be expected to improve the beneficiary s condition or prevent further regression so that treatment can be continued on a less intensive level of care, and proper treatment of the beneficiary s psychiatric condition requires services on an inpatient basis under the direction of a physician. BHM Healthcare Solutions
26 Areas To Focus On The member s symptoms: The symptoms of the beneficiary are characterized by a degree of intensity sufficient to require continual medical/nursing response, management, and monitoring Must be likely to respond well to treatment Are not characteristic of their baseline functioning (i.e. Intellectual Disability) Are an ACUTE exacerbation of dysfunctional behavioral patterns. Must have a high degree of intensity such that they cannot be managed safely on a lower level of care BHM Healthcare Solutions
27 Managing Care: IP BH Services Continued Stay Criteria (cont.) A Discharge Plan is a Deferred Treatment Plan and should be as specific and concrete as a Treatment Plan BHM Healthcare Solutions
28 Understanding Discharge The member s 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 ALWAYS ASK, What is the estimated discharge date and plan! BHM Healthcare Solutions
29 Contact Information Lynnette Gordon UM Director Phone: Network Operations Member specific questions or requesting a peer to peer BHM Healthcare Solutions
Psychiatric Residential Treatment Facility (PRTF): Aligning Care Efficiencies with Effective Treatment. BHM Healthcare Solutions 2013 1
Psychiatric Residential Treatment Facility (PRTF): Aligning Care Efficiencies with Effective Treatment 1 Presentation Objectives Attendees will have a thorough understanding of Psychiatric Residential
More informationInpatient Behavioral Health Services Clinical Coverage Policy No: 8-B Amended Date: August 1, 2014. 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 informationHAWAII ADMINISTRATIVE RULES TITLE 16 DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS CHAPTER 16
HAWAII ADMINISTRATIVE RULES TITLE 16 DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS CHAPTER 16 MENTAL HEALTH, ALCOHOL, AND DRUG ABUSE TREATMENT INSURANCE BENEFITS Subchapter 1 General Provisions 16-16-1 Purpose
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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 informationLevels of Care Criteria
Levels of Care Criteria Updated October 2011 E A N employee assistance network, inc. Doctor s Park, Suite 3-C 417 Biltmore Avenue Asheville NC 28801 800.454.1477 828.252.5725 Levels of Care Criteria Contents
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 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 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 informationHow To Treat A Mental Illness At Riveredge Hospital
ABOUT US n Riveredge Hospital maintains the treatment philosophy of Trauma Informed Care. n Our commitment to providing the highest quality of care includes offering Animal Assisted Therapy, and Expressive
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 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 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 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 information75-09.1-08-02. Program criteria. A social detoxi cation program must provide:
CHAPTER 75-09.1-08 SOCIAL DETOXIFICATION ASAM LEVEL III.2-D Section 75-09.1-08-01 De nitions 75-09.1-08-02 Program Criteria 75-09.1-08-03 Provider Criteria 75-09.1-08-04 Admission and Continued Stay Criteria
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 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 informationWashington State Regional Support Network (RSN)
Access to Care Standards 11/25/03 Eligibility Requirements for Authorization of Services for Medicaid Adults & Medicaid Older Adults Please note: The following standards reflect the most restrictive authorization
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 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 informationChildren s Community Health Plan INTENSIVE IN-HOME MENTAL HEALTH / SUBSTANCE ABUSE SERVICES ASSESSMENT AND RECOVERY / TREATMENT PLAN ATTACHMENT
Children s Community Health Plan INTENSIVE IN-HOME MENTAL HEALTH / SUBSTANCE ABUSE SERVICES ASSESSMENT AND RECOVERY / TREATMENT PLAN ATTACHMENT Please fax with CCHP prior authorization form to 608-252-0853
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 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 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 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 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 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 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 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 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 informationBrief Review of Common Mental Illnesses and Treatment
Brief Review of Common Mental Illnesses and Treatment Presentations to the Joint Subcommittee to Study Mental Health Services in the 21st Century September 9, 2014 Jack Barber, M.D. Medical Director Virginia
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 informationMedical Necessity Criteria Guidelines - Yale
Medical Necessity Criteria Guidelines - Yale Version 1.0 Effective Date: January 1, 2016 Updated: October 12, 2015 Medical Necessity Criteria Guidelines 2007-2016 Magellan Health, Inc. i Table of Contents
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 informationConceptual Models of Substance Use
Conceptual Models of Substance Use Different causal factors emphasized Different interventions based on conceptual models 1 Developing a Conceptual Model What is the nature of the disorder? Why causes
More informationPublic Act No. 15-226
Public Act No. 15-226 AN ACT CONCERNING HEALTH INSURANCE COVERAGE FOR MENTAL OR NERVOUS CONDITIONS. Be it enacted by the Senate and House of Representatives in General Assembly convened: Section 1. Section
More informationMembers must meet medical necessity criteria for a particular LOC. Medically necessary services are those services that:
BEACON HEALTH STRATEGIES, LLC. / MASSACHUSETTS LEVEL OF CARE CRITERIA LEVEL OF CARE CRITERIA Beacon s Level of Care (LOC) criteria were developed from the comparison of national, scientific and evidence
More informationResidential Treatment Facilities. ADMISSION CRITERIA (Must meet I and II or III)
Residential Treatment Facilities Admission of a child to a JCAHO Accredited Residential Treatment Facility is most appropriately based on a diagnosis by a certified child and adolescent psychiatrist. In
More informationMental Health and Substance Abuse Reporting Requirements Section 425 of P.A. 154 of 2005
Mental Health and Substance Abuse Reporting Requirements Section 425 of P.A. 154 of 2005 By April 1, 2006, the Department, in conjunction with the Department of Corrections, shall report the following
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 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 informationD. Clinical indicators for psychiatric evaluation are established by one or more of the following criteria. The consumer is:
MCCMH MCO Policy 2-015 Date: 4/21/11 V. Standards A. A psychiatric evaluation shall be done as an integral part of the assessment process. It serves as the guide to the identification of medical and psychiatric
More informationSchizoaffective Disorder
FACT SHEET 10 What Is? Schizoaffective disorder is a psychiatric disorder that affects about 0.5 percent of the population (one person in every two hundred). Similar to schizophrenia, this disorder is
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 informationInpatient Admission and Discharge Planning
Partners in Recovery POLICY AND STANDARDS Direct Care Clinics (DCC) Policy: Policy Number: PRG 3001 Policy Name: Date of Inception: Previous Approval Date: Current Approval Date: Corporate and Partners
More informationDepartment of Social and Health Services Division of Alcohol and Substance Abuse. WAC 388-805 Revision Recommendations Patient Placement Criteria
Department of Social and Health Services Division of Alcohol and Substance Abuse WAC 388-805 Revision Recommendations Patient Placement Criteria April 2003 WAC 388-805 WAC 388-805-005 What definitions
More informationOverview of the ASAM Patient Placement Criteria, Second Edition Revised (ASAM PPC-2R)
SAMHSA s Co-occurring Center for Excellence (COCE) Overview of the ASAM Patient Placement Criteria, Second Edition Revised (ASAM PPC-2R) David Mee-Lee, M.D. Chief Editor, ASAM PPC-2R www.dmlmd.com June
More information[KQ 804] FEBRUARY 2007 Sub. Code: 9105
[KQ 804] FEBRUARY 2007 Sub. Code: 9105 (Revised Regulations) Theory : Two hours and forty minutes Q.P. Code: 419105 Maximum : 100 marks Theory : 80 marks M.C.Q. : Twenty minutes M.C.Q. : 20 marks 1. A
More informationInitial Evaluation for Post-Traumatic Stress Disorder Examination
Initial Evaluation for Post-Traumatic Stress Disorder Examination Name: Date of Exam: SSN: C-number: Place of Exam: The following health care providers can perform initial examinations for PTSD. a board-certified
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 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 informationTREATING ADOLESCENTS
TREATING ADOLESCENTS A focus on adolescent substance abuse and addiction Center for Youth, Family, and Community Partnerships Presentation developed by: Christopher Townsend MA, LPC, LCAS,CCS, NCC Learning
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 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 informationWelcome New Employees. Clinical Aspects of Mental Health, Developmental Disabilities, Addictive Diseases & Co-Occurring Disorders
Welcome New Employees Clinical Aspects of Mental Health, Developmental Disabilities, Addictive Diseases & Co-Occurring Disorders After this presentation, you will be able to: Understand the term Serious
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 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 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 informationResidential Sub-Acute Detoxification Guidelines
I. Background Information A. Definition of Detoxification Residential Sub-Acute Detoxification Guidelines SAMSA s TIP #45, Detoxification and Substance Abuse Treatment: Treatment Improvement Protocols
More information- UNDERSTANDING - Dual Diagnosis
- UNDERSTANDING - Dual Diagnosis TABLE OF CONTENTS Introduction 3 The Link Between Mental Illness and Substance Abuse 4 Characteristics of an Effective Dual Diagnosis Treatment Plan 6 Dual Diagnosis Treatment
More informationTreatment Services for Individuals with Co-Occurring Mental Health and Intellectual Disability/Developmental Disabilities
Two types of individuals 1. People with primary diagnosis of intellectual disability/developmental disability Mental health diagnosis is secondary Primary services through ID/DD system Residential/Housing
More informationMental Disorders (Except initial PTSD and Eating Disorders) Examination
Mental Disorders (Except initial PTSD and Eating Disorders) Examination Name: Date of Exam: SSN: C-number: Place of Exam: The following health care providers can perform initial examinations for Mental
More informationTraumatic Stress. and Substance Use Problems
Traumatic Stress and Substance Use Problems The relation between substance use and trauma Research demonstrates a strong link between exposure to traumatic events and substance use problems. Many people
More information