Medical Necessity Criteria Guidelines. Adapted for. Magellan Behavioral Health of Nebraska, Inc.

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1 MAGELLAN HEALTHCARE, INC. Medical Necessity Criteria Guidelines Adapted for Magellan Behavioral Health of Nebraska, Inc V1 Effective Date: February 1, Magellan Health, Inc.

2 TOC Table of Contents Preamble- Principles of Medical Necessity Determinations... 5 Medical Necessity Definition... 7 Service Definitions... 8 MENTAL HEALTH SERVICES Acute Inpatient Hospital, Psychiatric, Adult Acute Inpatient Hospital, Psychiatric, Child and Adolescent Acute Inpatient, Eating Disorders Sub-acute Hospital, Psychiatric, Adult Hospital Observation Room Services (23:59) Psychiatric Residential Rehabilitation, Adult Secured Residential Rehabilitation, Psychiatric, Adult Crisis Stabilization, Adult Residential Treatment, Eating Disorders Psychiatric Residential Treatment Facility/Intensive Residential Treatment Facility (PRTF/IRTF), Mental Health Sexual Offender Mental Health Psychiatric Residential Treatment Facility (PRTF) Psychiatric Residential Treatment Facility (PRTF) Program for Individuals with Mild Cognitive Impairments.. 49 Mental Health Therapeutic Group Home (ThGH) Criteria Sexual Offense (SO) Therapeutic Group Home (ThGH) Criteria Professional Resource Family Care (PRFC), Child and Adolescent Partial Hospitalization, Adult Partial Hospitalization, Child and Adolescent Partial Hospitalization, Eating Disorders Assertive Community Treatment (ACT) and Alternative ACT Day Treatment, Mental Health, Adult Day Treatment, Mental Health, Child and Adolescent Intensive Outpatient Treatment, Psychiatric, Adult and Geriatric Intensive Outpatient Treatment, Mental Health, Child and Adolescent Intensive Outpatient Treatment, Eating Disorders Multi-Systemic Therapy (MST) Magellan Health, Inc. v1 2

3 Day Rehabilitation, Adult Psychiatric Nursing (In-Home), Adult Community Treatment Aide (CTA), Child and Adolescent Outpatient Treatment, Mental Health, Rehabilitation, Adult and Child/Adolescent Injectable Psychotropic Medications Electroconvulsive Therapy (ECT), Outpatient, Adult Psychological Evaluation and Testing Case Conferences, Child and Adolescent Comprehensive Child and Adolescent Assessment (CCAA) Community Support - Mental Health, Adult Sex Offender Risk Assessment (SORA) for Child and Adolescent SUBSTANCE USE DISORDER AND CO-OCCURRING DISORDER SERVICES Psychiatric Residential Treatment Facility (PRTF) Substance Use Disorder Specific Psychiatric Residential Treatment Facility (PRTF), Co-Occurring Disorder Co-Occurring Mental Health/Substance Use Disorder Therapeutic Group Home (ThGH) Criteria Co-Occurring Disorder Residential Adult - ASAM-Level 3.5 Enhanced* Short-term Residential Adult - ASAM-Level 3.5* Intermediate Residential Adult - ASAM-Level 3.3* Therapeutic Community Adult - ASAM-Level 3.3* Halfway House Adult - ASAM-Level 3.1* Outpatient COD Adult - ASAM-Level 1* Outpatient COD Child - ASAM-Level 1* IOP SUD Adult - ASAM-Level 2.1* IOP SUD Child - ASAM-Level 2.1* Outpatient SUD Adult - ASAM-Level 1* Outpatient SUD Child - ASAM-Level 1* Outpatient COD Adult - ASAM-Level 1* Outpatient COD Child - ASAM-Level 1* Community Support SUD Adult - ASAM-Level 1* 2015 Magellan Health, Inc. v1 3

4 Ambulatory Detox Adult - ASAM-Level 2D* Social Detox Adult - ASAM-Level 3.2* *The ASAM Criteria (current edition) is utilized to guide medical necessity decisions regarding these levels of care. Providers are responsible to refer to The ASAM Criteria manual for the complete criteria Magellan Health, Inc. v1 4

5 TOC Preamble- Principles of Medical Necessity Determinations Individualized, Needs-Based, Least-Restrictive Treatment Magellan Behavioral Health of Nebraska, Inc. (Magellan) has the belief that every individual is capable of recovery and resiliency. Magellan endeavors to promote care which is increasingly individualized, in which individuals and their families are empowered to achieve their goals, and in which all enrollees maximize their opportunities to live full lives in their own communities. Magellan is also committed to the philosophy of providing treatment at the most appropriate, least-restrictive level of care necessary to provide safe and effective treatment and meet the individual s biopsychosocial needs. We see the continuum of care as a fluid treatment pathway, where individuals may enter treatment at any level and be moved to more or less-intensive settings or levels of care as their changing clinical needs dictate. At any level of care, such treatment is individualized, active and takes into consideration the individual s stage of readiness to change/readiness to participate in treatment. The level of care criteria that follow are guidelines for determining medical necessity for Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5 ) disorders. Individuals may at times seek admission to clinical services for reasons other than medical necessity, e.g., to comply with a court order, to obtain shelter, to deter antisocial behavior, to deter runaway/truant behavior, to achieve family respite, etc. However, these factors do not alone determine a medical necessity decision. Further, coverage for services is subject to the limitations and conditions of the individual benefit plan. Specific information in the individual s contract and the benefit design for the plan dictate which medical necessity criteria are applicable. Although these Medical Necessity Criteria Guidelines are divided into Mental Health and Substance Use Disorder criteria sets to address the individual s primary problem requiring each level of care, psychiatric and substance-related disorders are often co-morbid. Thus, it is very important for all treatment facilities and providers to be able to assess these co-morbidities and address them along with the primary problem. Clinical Judgment and Exceptions Magellan s Medical Necessity Criteria Guidelines direct both providers and reviewers to the most appropriate level of care for an individual. While these criteria will assign the safest, most effective and least restrictive level of care in nearly all instances, an infrequent number of cases may fall beyond their definition and scope. Thorough and careful review of each case, including consultation with supervising clinicians, will identify these exceptions. As in the review of non-exceptional cases, clinical judgment consistent with the standards of good medical practice will be used to resolve these exceptional cases. All medical necessity decisions about proposed admission and/or treatment, other than outpatient, are made by the reviewer after receiving a sufficient description of the current clinical features of the individual s condition that have been gathered from a face-to-face evaluation of the individual by a qualified clinician. Medical necessity decisions about each individual are based on the clinical features of the individual relative to the individual s socio-cultural environment, the medical necessity criteria, and the real resources available. We recognize that a full array of 2015 Magellan Health, Inc. v1 5

6 services is not available everywhere. When a medically necessary level does not exist (e.g., rural locations), we will support the individual through extra-contractual benefits, or we will authorize a higher than otherwise necessary level of care to ensure that services are available that will meet the individual s essential needs for safe and effective treatment Magellan Health, Inc. v1 6

7 TOC Medical Necessity Definition Magellan reviews mental health and substance use disorder treatment for medical necessity. Based on Nebraska Administrative Code, Medical Necessity is defined as: The need for treatment services which are necessary to diagnose, treat, cure or prevent regression of significant functional impairments resulting from symptoms of a mental health or substance use disorder diagnosis. Treatment services shall: 1. Be provided in the least restrictive level of care that is appropriate to meet the needs of the client; and 2. Be supported by evidence that the treatment improves symptoms and functioning for the individual client s mental health or substance use disorder diagnosis; and 3. Be reasonably expected to improve the individual s condition or prevent further regression so that the services will no longer be necessary; and 4. Be required for reasons other than primarily for the convenience of the client or the provider. Each criteria set, within each level of care category is a more detailed elaboration of the above definition for the purposes of establishing medical necessity for these health care services. Each set is characterized by admission and continued stay criteria. The admission criteria are further delineated by severity of need and intensity and quality of service. 1 Particular rules in each criteria set apply in guiding a provider or reviewer to a medically necessary level of care (please note the possibility and consideration of exceptional individual situations described in the preamble when these rules may not apply). For admission, both the severity of need and the intensity and quality of service criteria must be met. The continued stay of an individual at a particular level of care requires the continued stay criteria to be met (Note: this often requires that the admission criteria are still fulfilled). Specific rules for the admission and continued stay groupings are noted within the criteria sets. 1 The only exceptions to this formatting style are the criteria sets related to PRTF. The PRTF medical necessity criteria are strictly based on CMS certification criteria; therefore, its formatting varies from the rest of the manual Magellan Health, Inc. v1 7

8 TOC Service Definitions Magellan believes that optimal, high-quality care is best delivered when individuals receive care that meets their needs in the least-intensive, least-restrictive setting possible. Magellan s philosophy is to endorse care that is safe and effective, and that maximizes the individual s independence in daily activity and functioning. Below are service definitions that are used in conjunction with Magellan s medical necessity criteria sets. Hospital-based Service Definitions are: 1) Acute Inpatient Hospital An Acute Inpatient program is designed to provide medically necessary, intensive assessment, psychiatric and/or eating disorder treatment and support to individuals with a DSM-5 diagnosis and/or co-occurring disorder experiencing an acute exacerbation of a psychiatric condition. The Acute Inpatient setting is equipped to serve individuals at high risk of harm to self or others and in need of a safe, secure, lockable setting. The purpose of the services provided within an Acute Inpatient setting is to stabilize the individual s acute psychiatric or eating disorder conditions. 2) Sub-Acute Hospital Subacute Inpatient hospital psychiatric services are medically necessary short-term psychiatric services provided to a client with a primary psychiatric diagnosis or co-occurring disorder experiencing an exacerbation of their condition. The Subacute Inpatient setting is equipped to serve individuals at some risk of harm to self or others and in need of a safe, secure, setting that is family centered, recovery oriented, culturally sensitive and developmentally appropriate. The purpose of sub-acute care is to provide further stabilization, engage consumer in comprehensive treatment, rehabilitation and recovery activities, and transitions client to least restrictive setting as rapidly as possible. 3) Hospital Observation Room Services (23:59) This level of care provides up to 23 hours and 59 minutes of care in a secure and protected environment. The program is medically staffed, psychiatrically supervised and includes continuous nursing services. The primary objective of this level of care is for prompt evaluation and/or stabilization of individuals presenting with acute symptoms or distress. Before or at admission, a comprehensive assessment is conducted and a treatment plan developed. The treatment plan should place emphasis on crisis intervention services necessary to stabilize and restore the individual to a level of functioning that does not require hospitalization. This level of care may also be used for a comprehensive assessment and to obtain clarification regarding previously incomplete diagnostic information that may lead to a determination that the individual requires a more intensive level of care. This service is not appropriate for individuals who by history or initial clinical presentation require services of an acute psychiatric inpatient setting exceeding 23 hours and 59 minutes. Duration of services at this level of care may not exceed 23 hours and 59 minutes, by which time stabilization and/or a determination of the appropriate level of care will be made, and facilitation of appropriate treatment and support linkages will be coordinated by the treatment team. 4) Partial Hospitalization (Psychiatric and Eating Disorder specific) 2015 Magellan Health, Inc. v1 8

9 Partial hospitalization is a nonresidential treatment program that is hospital-based. The program provides diagnostic and treatment services on a level of intensity similar to an inpatient program, but on less than a 24- hour basis. These services include therapeutic milieu, nursing, psychiatric evaluation, medication management, group, individual and family therapy. The environment at this level of treatment is highly structured, and there should be a staff-to-member ratio sufficient to ensure necessary therapeutic services. Partial Hospitalization may be appropriate as a time-limited response to stabilize acute symptoms, transition (step-down from inpatient), or as a stand-alone service to stabilize a deteriorating condition and avert hospitalization. Residential Service Definitions are: 1) Psychiatric Residential Rehabilitation Psychiatric Residential Rehabilitation is designed to provide individualized treatment and recovery inclusive of psychiatric rehabilitation and support for individuals with a severe and persistent mental illness and/or cooccurring disorder who are in need of recovery and rehabilitation activities within a residential setting of no more than 16 beds. Services must be community-based, family-centered, culturally competent, recovery oriented, trauma informed, and developmentally appropriate. The psychiatric residential rehabilitation program provides on-site psychosocial rehabilitation and skill acquisition activities. The program will facilitate clientdriven activities as appropriate. Psychiatric Residential Rehabilitation is provided by a treatment/recovery team in a 24-hour staffed residential facility. The intent of the service is to support the individual in the recovery process so that he/she can be successful in a community living setting of his/her choice. 2) Secure Psychiatric Residential Rehabilitation Secure Psychiatric Residential Rehabilitation is a secure facility-based, non-hospital or non-nursing facility program for individuals disabled by severe and persistent mental illness, who are unable to reside in a less restrictive setting. These facilities are integrated into the community and provide programming in an organized, structured setting, including treatment and rehabilitation services and offer support to clients with a severe and persistent mental illness and/or co-occurring substance use disorder disorders. These individuals demonstrate a moderate to high risk for harm to self/others and are in need of recovery, treatment, and rehabilitation services. The clients who are in need of this level of care have long standing limitations with limited ability to live independently over an extended period of time. These individuals have needed a high level of psychiatric intervention and have limitations in all three functional areas, vocational/educational, social skills and activities of daily living. See definitions in 471 NAC The Secure Psychiatric Residential Rehabilitation program provides skill building and other related recovery oriented psychiatric rehabilitation services as needed to meet individual client needs. The Secure Psychiatric Residential Rehabilitation Program is designed to: a) Increase the client's functioning while improving psychiatric stability so that s/he can eventually live successfully and safely in a less restrictive residential setting of his/her choice and capabilities; b) Decrease the frequency and duration of hospitalization; c) Decrease and/or eliminate all high risk, unsafe behavior to self or others; and d) Improve the ability to function independently by improving ability to function Magellan Health, Inc. v1 9

10 3) Residential, Eating Disorder Residential eating disorder treatment programs provider 24-hour onsite supervision and medical/nursing care to individuals who have significant eating disorder symptoms and are unable to be adequately treated in a community program. Treatment services include individual, group and family therapy, medical monitoring, dietary education and counseling and 24-hour nursing care. The goal of eating disorder residential treatment is to assist the member in developing internal controls and other adaptive functioning to assist the member in living outside of the residential setting. 4) Psychiatric Residential Treatment Facility (PRTF - MH, SO, SUD, COD) PRTF treatment provides 24-hour services for children/adolescents who have demonstrated severe and persistent psychiatric disorders, sexual offending disorders and/or substance use disorders. Children/adolescents receive therapeutic intervention and specialized programming, in a controlled environment with a high degree of supervision and structure. The program addresses the identified problems through a wide range of diagnostic and treatment services as well as through training in basic skills such as social skills and activities of daily living in the context of a comprehensive, interdisciplinary treatment plan. 5) Therapeutic Group Home (ThGH - MH, SO, COD) ThGHs deliver an array of clinical, treatment and related services, including psychiatric supports, integration with community resources and skill building taught within the context of a home like setting. ThGH treatment shall focus on reducing the severity of the behavioral health issues that were identified as the reasons for admission. Most often, targeted behaviors relate directly to the individual s ability to function successfully in the home and school environment (e.g., compliance with reasonable behavioral expectations, safe behavior and appropriate responses to social cues and conflicts). The goal of a ThGH is to maintain the individual s connections to the community yet receive and participate in a more intensive level of treatment in which the individual lives safely in a 24 hour setting. The emphasis of a ThGH is to restore the individual to an improved level of functioning in order that the individual may live and function in a less restrictive level of care. ThGHs are facilities specifically designed not to resemble institutions. ThGHs allow a small population of individuals to live in a home like environment with an organized, professional staff who deliver safety, supervision, rehabilitation services and treatment services. Treatment shall: a) Focus on reducing the behavior and symptoms of the mental health, sexual offending and/or substance use disorders that necessitated the removal of the individual from his or her usual living situation. b) Increase developmentally appropriate, normative and pro social behavior in individuals who are in need of out of home treatment. 6) Co-Occurring Disorder Residential Treatment Co-Occurring Disorder Residential Treatment is intended for adults with a primary diagnosis of substance dependence and a co-occurring severe and persistent mental illness requiring a more restrictive treatment environment to prevent substance use. This service is highly structured, based on acuity, and provides primary, 2015 Magellan Health, Inc. v1 10

11 integrated treatment to further stabilize acute symptoms and engage the individual in a program of maintenance, treatment, rehabilitation and recovery. Co-Occurring Disorder Residential Treatment is provided in units of 16 beds or fewer. This service may be located in a community setting or a specialty unit within a licensed health care facility. Level 3.5 programs are designed to treat persons who have significant social and psychological problems. Such programs are characterized by their reliance on the treatment community as a therapeutic agent. The goals of treatment are to promote abstinence from substance use and antisocial behavior and to effect a global change in participant s lifestyle, attitudes and values. This philosophy views substance-related problem as disorders of the whole person that are reflected in problems with conduct, attitudes, moods, values, and emotional management. The defined characteristics of these residents are found in their emotional, behavioral and cognitive conditions and their living environments. Individuals who are appropriately placed in a Level3.5 program typically have multiple deficits, which may include substance-related disorders, criminal activity, psychological problems, impaired functioning and disaffiliation from mainstream values. 7) Short Term Residential Treatment Short Term Residential Treatment is intended for adults with a primary diagnosis of substance dependence requiring a more restrictive treatment environment to prevent the use of abused substances. This service is highly structured, is provided in programs of no more than 16 beds, and provides primary, comprehensive substance use disorder treatment. This service may be located in a community setting or a specialty unit within a licensed health care facility. Level 3.5 programs are designed to treat persons who have significant social and psychological problems. Such programs are characterized by their reliance on the treatment community as a therapeutic agent. The goals of treatment are to promote abstinence from substance use and antisocial behavior and to effect a global change in participant s lifestyle, attitudes and values. This philosophy views substancerelated problem as disorders of the whole person that are reflected in problems with conduct, attitudes, moods, values, and emotional management. The defined characteristics of these residents are found in their emotional, behavioral and cognitive conditions and their living environments. Individuals who are appropriately placed in a Level 3.5 program typically have multiple deficits, which may include substance-related disorders, criminal activity, psychological problems, impaired functioning and disaffiliation from mainstream values. Their mental disorders may involve serious and persistent mental health issues. Other functional deficits in residents appropriately placed at this level of care include a constellation of criminal history or antisocial behaviors, with a risk of continued criminal behavior, and extensive history of treatment and /or criminal justice involvement, limited education, little or no work history and limited vocational skills. Poor social skills, inadequate anger management skills, extreme impulsivity, emotional immaturity and /or an antisocial value system. 8) Intermediate Residential Treatment Intermediate Residential Treatment is intended for adults with a primary diagnosis of substance dependence for whom shorter term treatment is inappropriate, either because of the pervasiveness of the impact of dependence on the individual s life or because of a history of repeated short-term or less restrictive treatment failures. Typically this service is more supportive than therapeutic communities and relies less on peer dynamics in its treatment approach. Individuals are housed in, or affiliated with, permanent facilities where they can reside safely. Level 3.3 programs provide structured recovery environment of no more than 16 beds in combination with medium intensity clinical services to support recovery from substance-related disorders. These programs are frequently referred to as extended or long-term care. For the typical resident in a Level 3.3 program, the effects of the substance-related disorder on the individual s life are so significant, and the resulting level of impairment so great, that outpatient motivational and/ or relapse prevention strategies are not feasible or effective. The functional deficits seen in individuals who are appropriately placed at Level 3.3 are primarily 2015 Magellan Health, Inc. v1 11

12 cognitive and can be either temporary or permanent. They may result in problems in interpersonal relationships or emotional coping skills. Some individuals have such severe deficits in interpersonal and coping skills that the treatment process is one of habilitation rather than rehabilitation. Treatment of such individuals is directed toward overcoming their lack of awareness of the effects of substance-related problems on their lives, as well as enhancing their readiness to change. Treatment also is focused on preventing relapse, continued problems and/or continued use, and promoting the eventual reintegration of the individual into the community. In every case, the individual should be involved in planning continuing care to support recovery and improve his or her functioning. 9) Therapeutic Community Therapeutic Community is intended for adults with a primary diagnosis of substance dependence for whom shorter term treatment is inappropriate, either because of the pervasiveness of the impact of dependence on the individual s life or because of a history of repeated short-term or less restrictive treatment failures. This service provides psychosocial skill building through a set of longer term, highly structured peer oriented treatment activities which define progress toward individual change and rehabilitation and which incorporate a series of defined phases. The individual s progress must be marked by advancement through these phases to less restrictiveness and more personal responsibility. Individuals are housed in, or affiliated with, permanent facilities where they can reside safely. Level 3.3 programs provide structured recovery environment in combination with medium intensity clinical services to support recovery from substance-related disorders. These programs are frequently referred to as extended or long-term care. For the typical resident in a Level 3.3 program, the effects of the substance-related disorder on the individual s life are so significant, and the resulting level of impairment so great, that outpatient motivational and/ or relapse prevention strategies are not feasible or effective. The functional deficits seen in individuals who are appropriately placed at Level 3.3 are primarily cognitive and can be either temporary or permanent. They may result in problems in interpersonal relationships or emotional coping skills. Some individuals have such severe deficits in interpersonal and coping skills that the treatment process is one of habilitation rather than rehabilitation. Treatment of such individuals is directed toward overcoming their lack of awareness of the effects of substance-related problems on their lives, as well as enhancing their readiness to change. Treatment also is focused on preventing relapse, continued problems and/or continued use, and promoting the eventual reintegration of the individual into the community. In every case, the individual should be involved in planning continuing care to support recovery and improve his or her functioning. 10) Halfway House Halfway House is a transitional, 24-hour structured supportive living/treatment/recovery facility of no more than 16 beds, located in the community for adults seeking reintegration into the community generally after primary treatment at a more intense level. This service provides safe housing, structure and support, affording individuals an opportunity to develop and practice their interpersonal and group living skills, strengthen recovery skills and reintegrate into their community, find/return to employment or enroll in school. The services provided usually include, individual, group and family therapy; medication management and medication education. Mutual/self-help meetings usually are available on site. Some persons require the structure of a Level 3.1 program to achieve engagement in treatment. Those who are in the early stages of readiness to change may need to be removed from an unsupportive living environment in order to minimize their continued alcohol or other drug use. Level 3.1 programs can also meet the needs of individuals who may not yet acknowledge that they have an alcohol or other drug problem. Such individuals may be living in a recovery environment that is too toxic to permit treatment on an outpatient basis. Because these individuals are at an early stage of readiness to change, they many need monitoring and motivating strategies to prevent deterioration engage them in treatment and facilitate their progress through the stages of change to recovery. They are appropriately placed in 2015 Magellan Health, Inc. v1 12

13 a Level 3.1 supportive environment while receiving discovery services as opposed to recovery services. In every case, the individual should be involved in planning continuing care to support recovery and improve his or her functioning. 11) Social Detox Social Detox provides intervention in substance use disorder emergencies on a 24-hour/day basis for acutely intoxicated individuals to restore from intoxicated state. Provides residential setting with staff present for observation, monitoring of vital signs, administration of fluids, provision for rest and substance use disorder education, counseling and referral. Length of service varies depending on individual needs but is usually not longer than 2-5 days. CPC is a 24-hour legal hold that law enforcement can use to provide safety for the intoxicated person presented a danger to him/herself and/or others. The Social Detox facility may have 1-4 locked rooms available for a CPC involuntary hold to provide protection and detoxification services. 12) Crisis Stabilization Crisis Stabilization provides a facility-based program where individuals in urgent/emergency need can receive crisis stabilization services in a safe, structured setting. It provides continuous 24-hour observation and supervision for individuals who do not require intensive clinical treatment in an inpatient psychiatric setting and would benefit from a short-term, structured stabilization setting. Services at this level of care include crisis stabilization, initial and continuing assessment, care management, medication management, and mobilization of family support and community resources. This level of care may or may not be provided in a medical setting. Some of the functions such as medication monitoring and physical care will require access to medical services while other services can be provided by mental health professionals who are licensed and credentialed to provide interventions such as individual therapy, family therapy, and crisis counseling. This level of care would provide an initial assessment by a licensed mental health professional prior to admission followed by a comprehensive psychiatric evaluation by a psychiatrist within 24 hours. The primary objective of the crisis stabilization service is to promptly conduct a comprehensive assessment of the individual and to develop a treatment plan with emphasis on crisis intervention services necessary to stabilize and restore the individual to a level of functioning which requires a less restrictive level of care. Duration of services should not exceed 72 hours, by which time a determination of the appropriate level of care will be made and facilitation of appropriate linkages coordinated by the treatment team. Community-based Service Definitions are 1) Professional Resource Family Care (PRFC) PRFC is intended to serve as crisis stabilization option for a family in order to avoid psychiatric inpatient and institutional treatment of the individual by utilizing of a co parenting approach provided in a surrogate family setting. During the time the professional resource family is supporting the individual, there is regular contact with the individual s family to prepare for the individual's return and to support his/her ongoing needs as part of the family. It is expected that the individual, family, and professional resource family are integral to the individual s treatment team. PRFC programs perform the following functions: a) Promotes improvement in the individual s social skills and family/peer relationships skills through training and education of the individual and the usual caregiver Magellan Health, Inc. v1 13

14 b) Teaches the caregivers or parents crisis and de escalation techniques. c) Teaches and models appropriate behavioral treatment interventions and techniques to the individual and the individual s caregiver or parents. d) Teaches and models appropriate coping skills to manage dysfunctional behavior to the individual and the individual s caregiver or parents. e) Teaches and models proper and effective parenting practice to biological parents or the individual s primary caregiver. f) Provides information about medication compliance and relapse prevention to the prescribing and/or Supervising Practitioner. g) Provides training and rehabilitation of basic personal care and activities of daily living by training the individual and the usual caregiver or parent. h) Helps the individual develop positive peer relationships. i) Works with the family to explore community resources in the individual and families natural setting. PRFC parents are supported and guided by a PRFC team and agency under the direction of a PRFC supervisor. The PRFC team is responsible for supporting and supervising the work of the surrogate parents, and ensuring coordination and collaboration between the individual family and the surrogate parents. This family collaboration is a necessary and essential function of this family rehabilitation model. 2) Assertive Community Treatment (ACT) The Assertive Community Treatment (ACT) Team provides high intensity services, and is available to provide treatment, rehabilitation, and support activities seven days per week, twenty-four hours per day, 365 days per year. The team has the capacity to provide multiple contacts each day as dictated by client need. The team provides ongoing continuous care for an extended period of time, and clients admitted to the service and demonstrating any continued need for treatment, rehabilitation, or support will not be discharged except by mutual agreement between the client and the team. The primary goal of the Assertive Community Treatment (ACT) is to assist clients disabled by severe and persistent mental illness to have an improved quality of life and increased success in stable community living. This model of integrated treatment, rehabilitation and support services by multidisciplinary team staff is intended to help clients stabilize symptoms, improve level of functioning, and enhance their sense of well-being and empowerment. While the majority of services provided will focus on treatment and rehabilitation of the affects of serious mental illness, support and assistance in meeting such basic human needs as housing, transportation, education, and employment is necessary for client satisfaction with services and increased quality of life. The philosophy of the program is to provide assistance to clients to maximize their recovery, to insure client directed goal setting, to assist clients in gaining hope and sense of empowerment, and provide assistance in helping clients become respected and valuable members of the community. 3) Day Treatment Day Treatment provides a community based, coordinated set of individualized treatment services to individuals with psychiatric disorders who are not able to function full-time in a normal school, work, and/or home 2015 Magellan Health, Inc. v1 14

15 environment and need the additional structured activities of this level of care. While less intensive than partial hospitalization, this service includes diagnostic, medical, psychiatric, psychosocial, and adjunctive treatment modalities in a structured setting. Day Treatment programs typically are less medically involved than partial hospital programs. 4) Intensive Outpatient Psychotherapy (MH, SO, SUD, COD, Eating Disorder) Intensive Outpatient Psychotherapy services provide group based, non-residential, intensive, structured interventions consisting primarily of counseling and education to improve mental health, sexual offending, substance use disorder and/or eating disorder symptoms that may significantly interfere with functioning in at least one life domain (e.g., familial, social, occupational, educational, etc.). Services are goal oriented interactions with the individual or in group/family settings. This community based service allows the individual to apply skills in real world environments. Such treatment may be offered during the day, before or after work or school, in the evening or on a weekend. The services follow a defined set of policies and procedures or clinical protocols. The service also provides a coordinated set of individualized treatment services to persons who are able to function in a school, work, and home environment but are in need of treatment services beyond traditional outpatient programs. Treatment may appropriately be used to transition persons from higher levels of care or may be provided for persons at risk of being admitted to higher levels of care. The goals, frequency, and duration of outpatient treatment will vary according to individual needs and response to treatment. 5) Multi-Systemic Therapy (MST) MST services are targeted for youth ages years old. MST provides an intensive home/family and community-based treatment for youth who are at risk of out-of-home placement or who are returning from out-of-home placement. The MST model is based on empirical data and evidence-based interventions that target specific behaviors with individualized behavioral interventions. Services are primarily provided in the home, but workers also intervene at school and in other community settings. All MST services must be provided to, or directed exclusively toward, the treatment of the Medicaid-eligible youth. The duration for MST services is 3-6 months but, typically no longer than six months. The therapist meets with the youth and family at least weekly but often over a four month period, as well as about 35 hours of non-direct contact provided to the ecology of the youth (e.g., consultation and collaboration with other systems). 6) Day Rehabilitation Day Rehabilitation services are designed to provide individualized treatment and recovery, inclusive of psychiatric rehabilitation and support for clients with a severe and persistent mental illness and/or co-occurring disorders who are in need of a program operating variable hours. Services must be community-based, familycentered, culturally competent, recovery oriented, trauma informed, and developmentally appropriate. The psychiatric day rehabilitation program provides on-site psychosocial rehabilitation and skill acquisition activities. The intent of the service is to support the individual in the recovery process so that he/she can be successful in a community living setting of his/her choice. 7) Psychiatric nursing (in home) Psychiatric nursing (in home) or Mental Health Home Health Services are provided to clients in their place of residence. (The place of residence does not include a hospital, skilled nursing facility, day rehabilitation program, residential rehabilitation facility, or adult day treatment program.) The home health service is provided by a licensed registered nurse to clients who are unable to access office-based services. This service is only available to homebound. ( Homebound is defined as an individual whose medical or psychiatric condition restricts 2015 Magellan Health, Inc. v1 15

16 their ability to leave home safely without the assistance or supervision of another individual or without the assistance of a supportive device and the individual leaves home only to receive medical/psychiatric treatment or leaves home infrequently for non-medical purposes. ) Typically the client has a very poor support system within the community, (no family or interested party to act as caretaker, family members or interested parties exist but have poor insight into the client s psychiatric condition and have no positive impact in assisting in the improvement of the client s psychiatric/medical condition). Services may include medication administration, assistance in setting up a medication system, teaching and monitoring of medication, and observation of the physical well-being in relation to medication side effects. The service is intended to support and facilitate increased coordination with rehabilitation services such as community support services. This service is not intended to replace the direct involvement of a physician/psychiatrist in the treatment of the individual. 8) Community Treatment Aide (CTA) Community Treatment Aide (CTA) services are supportive and psychoeducational interventions designed to assist the individual and parents or primary caregivers to learn and rehearse the specific strategies and techniques that can decrease the severity of, or eliminate, symptoms and behaviors associated with the individual s mental illness that create significant impairments in functioning. The individual s CTA plan shall be a part of the comprehensive treatment plan developed by the individual s outpatient psychotherapy provider and be developed in close collaboration with the therapy provider. The CTA interventions, the individual s progress and modifications to the CTA plan shall be reviewed and approved by the outpatient therapist and shall be documented by the CTA and the therapist. 9) Outpatient psychotherapy (MH, SO, SUD, COD) Outpatient psychotherapy is for the treatment of mental health, sexual offending, and/or substance use disorder symptoms related to a DSM-5 diagnosis through scheduled therapeutic visits between the therapist and the member. Outpatient psychotherapy is expected to improve active symptoms of the identified individual that significantly interfere with the member s functioning in at least one life domain (e.g., familial, social, occupational, educational, etc.). The goals, frequency and duration of outpatient treatment will vary according to the individual s needs and response to treatment. Individuals other than the identified individual may participate in the individual session with the identified individual to assist in achieving the individual s treatment goals. Outpatient group psychotherapy is active treatment of a DSM-5 mental health, sexual offending and/or substance use disorder through scheduled treatment interventions with a common goal in the context of a group setting. A group is described as at least three individuals and no more than 12 individuals facilitated by a licensed practitioner. The focus of outpatient group psychotherapy treatment is to improve the member s ability to function as well as alleviate symptoms related to their diagnosis that may significantly interfere with their functioning. The goals, frequency, and duration of outpatient group treatment will vary according to individual needs and response to treatment. Outpatient family psychotherapy is a therapeutic encounter between the licensed treatment professional, the member and the member s family. The specific objective of active treatment must be to increase the functional level of the family in support of the identified individual s mental health, sexual offending and/or substance use active diagnostic symptoms. This therapeutic intervention must be provided with the identified individual who has a current DSM-5 diagnosis and family members present. 10) Injectable Psychiatric Medication 2015 Magellan Health, Inc. v1 16

17 Injectable Psychiatric Medication is the initial evaluation of the individual's need for injectable psychotropic medications, the provision of a prescription as needed, and ongoing medical monitoring/evaluation related to the individual s use of the injectable psychotropic medication. 11) Electroconvulsive Therapy, Outpatient (ECT) ECT is a treatment where an electric current, which is medically controlled, is applied to either or both sides of the brain (unilaterally vs. bilaterally) for the purpose of producing a seizure that is modulated by anesthesia and muscle relaxants. 12) Psychological Evaluation and Testing Psychological Testing is defined as the use of one or more standardized measurements, instruments or procedures to observe or record human behavior, and requires the application of appropriate normative data for interpretation or classification. Psychological testing may be used to either assist in differential diagnosis of psychiatric disorders or to assist in the assessment of response of those disorders to treatment. 13) Case Conference A case conference is the sharing of clinical information about the individual with the parents and/or legal guardians or other involved parties, such as the school system accessed by the youth. It is a treatment intervention, must be identified in the individual s treatment plan and requires a progress note. The outcome is expected to improve the individual s condition. It is done face to face with the responsible person. 14) Comprehensive Child and Adolescent Assessment The Comprehensive Child and Adolescent Assessment is an in-depth multidisciplinary assessment of the behavioral health and substance use needs of youth, age 18 and younger. 15) Community Support (Mental Health) Community Support is a rehabilitative and support service for individuals with primary diagnosis consistent with a serious and persistent mental illness. Community Support Workers provide direct rehabilitation and support services to the individual in the community with the intention of supporting the individual to maintain stable community living, and prevent exacerbation of mental illness and admission to higher levels of care. Service is not provided during the same service delivery hour of other rehabilitation services. 16) Community Support (Substance Use Disorder) Level I: Community Support is rehabilitation and support service for individuals with primary diagnosis of substance dependence. Community Support Workers provide direct rehabilitation and support services to the individual in the community with the intention of supporting the individual to maintain abstinence, stable community living, and prevent exacerbation of illness and admission to higher levels of care. Community Support describes the professionally directed evaluation, and recovery services for individuals experiencing a substance related disorder that causes moderate and/or acute disruptions in the individual s life. While the services follow a defined set of policies and procedures or clinical protocols, they must be tailored to each individual s level of clinical severity and must be designed to help the individual achieve changes in his or her alcohol or other drug using behaviors. The service must address major lifestyle, attitudinal and behavior issues that may undermine treatment goals or impair the individual s ability to function in at least one life area. Service 2015 Magellan Health, Inc. v1 17

18 is not provided during the same service delivery hour of other rehabilitation services; with the exception of availability for individuals 30 days prior to discharging from a 24 hour treatment setting. 17) Sex Offender Risk Assessment This specialized assessment is used to assess risk for ongoing deviant sexual behavior of a youth, under age 18, following a documented sexual offense. The risk assessment is done by a provider with extensive knowledge and expertise in assessing and treatment of juvenile sexual offenders. The provider will utilize a validated sexual risk assessment tool in order to evaluate risk and make treatment recommendations Magellan Health, Inc. v1 18

19 TOC MENTAL HEALTH SERVICES 2015 Magellan Health, Inc. v1 19

20 TOC Acute Inpatient Hospital, Psychiatric, Adult Criteria for Admission The specified requirements for severity of need and intensity and quality of service must be met to satisfy the criteria for admission. I. Admission - Severity of Need Criteria A and B and one of C, D or E must be met to satisfy the criteria for severity of need. A. The individual has a diagnosed or suspected mental illness. Mental illness is defined as a psychiatric disorder that, by accepted medical standards, can be expected to improve significantly through medically necessary and appropriate therapy. Presence of the illness(es) must be documented through the assignment of appropriate DSM- 5 codes. B. The individual requires an individual plan of active psychiatric treatment that includes 24-hour access to the full spectrum of psychiatric staffing. This psychiatric staffing must provide 24-hour services in a controlled environment that may include but is not limited to medication monitoring and administration, other therapeutic interventions, quiet room, restrictive safety measures, and suicidal/homicidal observation and precautions. C. The individual demonstrates a clear and reasonable inference of imminent serious harm to self. This is evidenced by having any one of the following: 1) a current plan or intent to harm self with an available and lethal means, or 2) a recent lethal attempt to harm self with continued imminent risk as demonstrated by poor impulse control or an inability to plan reliably for safety, or 3) an imminently dangerous inability to care adequately for his/her own physical needs or to participate in such care due to disordered, disorganized or bizarre behavior, or 4) other similarly clear and reasonable evidence of imminent serious harm to self. D. The individual demonstrates a clear and reasonable inference of imminent serious harm to others. This is evidenced by having any one of the following: 1) a current plan or intent to harm others with an available and lethal means, or 2) a recent lethal attempt to harm others with continued imminent risk as demonstrated by poor impulse control and an inability to plan reliably for safety, or 3) violent unpredictable or uncontrolled behavior that represents an imminent risk of serious harm to the body or property of others, or 2015 Magellan Health, Inc. v1 20

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