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THE MIHALIK GROUP’S

MEDICAL NECESSITY MANUAL

FOR

BEHAVIORAL HEALTH VERSION 7.0.1

SEPTEMBER 1, 2012

Medical Necessity Manual for Behavioral Health

Version 7.0.1

September 1, 2012

Licensed to LifeSynch under agreement with The Mihalik Group

Copyright Notice

©1998-2012 The Mihalik Group Page i

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Table of Contents

©1998-2012 The Mihalik Group Page ii

Acknowledgements ......................................................................................................................v Plan-Specific Amendments ..........................................................................................................vi Introduction ..................................................................................................................................1

Review and Revision of Version 7.0.1 ............................................................................2 How To Use This Manual ................................................................................................3 Making Medical Necessity Determinations .....................................................................6 Plan Specific Modifications .............................................................................................8 Contacting The Mihalik Group ........................................................................................9

Service Setting Criteria ................................................................................................................10 About The Service Setting Criteria ..................................................................................11

Acute Inpatient: Mental Health .......................................................................................12 Acute Inpatient: Substance Related ................................................................................14 23-Hour Inpatient Observation ........................................................................................16 Sub-Acute Inpatient (Residential): Mental Health .........................................................18

Sub-Acute Inpatient (Residential): Substance Related ...................................................20 Respite Inpatient: Mental Health ....................................................................................23

Therapeutic Foster Care ...................................................................................................25 Supervised Community Residential Care ........................................................................27 Partial Hospital: Mental Health ......................................................................................29

Partial Hospital: Substance Related ................................................................................31 Intensive Outpatient: Mental Health ...............................................................................33

Intensive Outpatient: Substance Related ........................................................................35

Outpatient Crisis Intervention ..........................................................................................37

Mobile Team ....................................................................................................................39 Home Health Services......................................................................................................40

Traditional Outpatient: Mental Health ............................................................................42 Traditional Outpatient: Substance Related .....................................................................43

Adult Level Of Care Criteria .......................................................................................................44

Acute Inpatient Treatment: Mental Health .....................................................................45 Acute Inpatient Treatment: Substance Related ...............................................................48 23-Hour Inpatient Observation ........................................................................................50 Sub-Acute Inpatient (Residential) Treatment: Mental Health ........................................52

Sub-Acute Inpatient (Residential) Treatment: Substance Related ..................................54 Respite Inpatient Care: Mental Health ............................................................................57 Supervised Community Residential Care/Group Home ..................................................59

Partial Hospital Treatment: Mental Health .....................................................................61 Partial Hospital Treatment: Substance Related...............................................................64 Intensive Outpatient Treatment: Mental Health .............................................................67 Intensive Outpatient Treatment: Substance Related .......................................................69

Outpatient Crisis Intervention ..........................................................................................71 Mobile Team ....................................................................................................................73 Home Health Services......................................................................................................75

Traditional Outpatient Treatment: Mental Health ..........................................................77


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©1998-2012 The Mihalik Group Page iii

Traditional Outpatient Treatment: Substance Related ....................................................79 Child And Adolescent Level Of Care Criteria .............................................................................81

Acute Inpatient Treatment: Mental Health .....................................................................82

Acute Inpatient Treatment: Substance Related ...............................................................85 23-Hour Inpatient Observation ........................................................................................87 Sub-Acute Inpatient (Residential) Treatment: Mental Health ........................................89 Sub-Acute Inpatient (Residential) Treatment: Substance Related ..................................91 Supervised Community Residential Care/Group Home ..................................................94

Therapeutic Foster Care ...................................................................................................96 Partial Hospital Treatment: Mental Health .....................................................................98

Partial Hospital Treatment: Substance Related...............................................................101 Intensive Outpatient Treatment: Mental Health .............................................................104 Intensive Outpatient Treatment: Substance Related .......................................................107 Outpatient Crisis Intervention ..........................................................................................110

Mobile Team ....................................................................................................................112 Home Health Services......................................................................................................114

Traditional Outpatient Treatment: Mental Health ..........................................................116 Traditional Outpatient Treatment: Substance Related ....................................................119

Geriatric Level Of Care Criteria ..................................................................................................122

Acute Inpatient Treatment: Mental Health .....................................................................123 Acute Inpatient Treatment: Substance Related ...............................................................126

23-Hour Inpatient Observation ........................................................................................128

Sub-Acute Inpatient (Residential) Treatment: Mental Health ........................................130

Sub-Acute Inpatient (Residential) Treatment: Substance Related ..................................132 Respite Inpatient Care: Mental Health ............................................................................135

Supervised Community Residential Care/Group Home ..................................................137 Partial Hospital Treatment: Mental Health .....................................................................139 Partial Hospital Treatment: Substance Related...............................................................142

Intensive Outpatient Treatment: Mental Health .............................................................145 Intensive Outpatient Treatment: Substance Related .......................................................148 Outpatient Crisis Intervention ..........................................................................................151 Mobile Team ....................................................................................................................153

Home Health Services......................................................................................................155 Traditional Outpatient Treatment: Mental Health ..........................................................157 Traditional Outpatient Treatment: Substance Related ....................................................160

Additional Clinical Criteria ..........................................................................................................163 Psychological and Neuropsychological Testing ..............................................................164 Substance Use Requiring Medical Detoxification ...........................................................167 Eating Disorders...............................................................................................................169

Electroconvulsive Therapy ..............................................................................................177 Applied Behavior Analysis: Outpatient Treatment.........................................................180

Appendices ...................................................................................................................................184

Appendix I: Assessing Dangerousness ...........................................................................185


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©1998-2012 The Mihalik Group Page iv

Appendix II: Diagnoses Generally Considered To Have A Treatable Biological

Component ...........................................................................................................189 Appendix III: Treatments Generally Excluded From Coverage .....................................190

References ....................................................................................................................................191


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Acknowledgements

©1998-2012 The Mihalik Group Page v

ACKNOWLEDGEMENTS

The Mihalik Group gratefully acknowledges the contributions of the members of its National

Advisory Panel for their advice during the review and revision process for The Mihalik Group’s

Medical Necessity Manual for Behavioral Health. The Mihalik Group assumes all responsibility

for the final contents of this Manual.

The members of the National Advisory Panel are:

Frank J. Pieri, MD, MBA

Chairman

Private Practice

Chicago, IL

Ken C. Hopper, MD, MBA

Owner

The Hopper Group: A Medical Behavioral

Health Clinic

Arlington, TX

Peggy Ebinger, MD, FAPA

Medical Director

Child Psychiatrist

Optima Health

Virginia Beach, VA

Madeleine Kolar, MD

Associate Behavioral Health Medical Director

Anthem Blue Cross Blue Shield

Indianapolis, IN

Gail A. Edelsohn, MD, MSPH

Senior Medical Director, Quality

Community Care Behavioral Health

Organization

Exton, PA

Claudia Lamazares, M.Ed, LMHC, MBA

General Manager

Magellan Behavioral Health of Florida

Magellan Health Services

Miami, FL

Larry Gard, PhD

President

Hamilton-Chase Consulting

Chicago, IL

Milton Nidetz, LCSW, BCD

Private Practice, Currently Retired

Skokie, IL

Lawrence D. Ginsberg, MD

Red Oak Psychiatry Association, P.A.

Houston, TX

Sean M. Reardon, PhD, LP

Associate Professor, Clinical Psychology

Argosy University, Twin Cities

Eagan, MN

The development of the Applied Behavior Analysis: Outpatient Treatment Criteria in 2011

would not have been possible without the efforts of Peggy Ebinger, MD, FAPA of Optima

Health and RaeAnn Taylor, PhD, Tibi Bodea, MD, Virginia Johnson, PhD, Lori Nelsen-

Luneburg, PhD, Todd Dryer, PhD and Duncan Bruce, MA of Community Care Behavioral

Health Organization.


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©1998-2012 The Mihalik Group Page vi

PLAN-SPECIFIC AMENDMENTS


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Plan Specific Amendments

©1998-2012 The Mihalik Group Page vii

DISCLAIMER

The information in this “Plan Specific Amendments” section is provided by, and is specific to,

LifeSynch - Irving, Texas. The Mihalik Group disclaims any and all responsibility for the

information in this section.

Parenthetical comments were added indicating that the term Sub-Acute Inpatient is synonymous

with Residential.


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©1998-2012 The Mihalik Group Page 1

INTRODUCTION


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Introduction


REVIEW AND REVISION OF VERSION 7.0.1

As part of The Mihalik Group’s ongoing work to maintain the comprehensive nature of its

Medical Necessity Manual for Behavioral Health, a review was undertaken under the oversight

of a National Advisory Panel comprised of behavioral health specialists from a variety of

backgrounds and experiences. As a result of this review:

The definition of “caregiver” was added to the Criteria for Applied Behavioral Analysis.

References have been updated.

No other substantive revisions were made to the Manual.


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Introduction


HOW TO USE THIS MANUAL

This manual is laid out in four chapters plus several appendices and a selected reference list.

Medical necessity decisions involve consideration of two related, but distinct, dimensions:

1. The characteristics of the service setting.

2. The medical necessity of the proposed services.

Both of these dimensions are addressed in this manual.

The first chapter, “Service Setting Criteria,” describes the characteristics of each treatment

setting for which this manual contains treatment initiation and treatment continuation criteria.

Staff making utilization management decisions should be familiar with the characteristics of each

treatment setting. For example, a major difference between acute inpatient and sub-acute

inpatient settings is the presence of professional nursing staff on all shifts for the former, versus

the presence of twenty-four hour per day supervision by non-nursing behavioral health personnel

for the latter. This difference is a crucial one when deciding on the appropriate level of care for a

specific individual and is matched by a Level of Care criterion that addresses this difference.

Since the Service Setting Criteria are not usually individually evaluated each time care is

authorized in that setting, they have been collected into a separate section. Managed care,

including managed behavioral health care, organizations can use these criteria in network

development to identify which levels of care are provided by a specific organization. Health care

delivery organizations can use them for their own internal review processes. For example, to

determine if a particular level of care is being provided according to these national norms.

Commonly, in day-to-day care management, utilization management staff will rely on the

assumption that a facility contracted to provide a specific treatment setting meets the appropriate

Service Setting Criteria. The Service Setting Criteria, however, are routinely used in certain

utilization management situations. Two examples follow.

If an individual needs to be admitted to treatment at a non-network facility, utilization

management staff can use these criteria to verify that the facility’s treatment program meets

Service Setting Criteria for the level of care being authorized.

Utilization management decisions made based on review of treatment records can permit

application of Service Setting Criteria that can be difficult to consistently apply in telephonic

reviews. For example, the psychiatric evaluation of a newly admitted individual may have

occurred later than described in the Service Setting Criteria thereby delaying definitive treatment

and extending the length of the treatment episode. Lack of compliance with this particular

Service Setting Criterion could have an impact on the utilization management decision.

The second chapter contains Adult Level of Care Criteria. Chapters for Child and Adolescent

Level of Care Criteria and Geriatric Level of Care Criteria follow. The next chapter, Additional

Clinical Criteria, contains criteria for psychological testing, detoxification and eating disorders.

The process for applying the Level of Care Criteria is described in the section on “Making

Medical Necessity Determinations.”


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Introduction


Each Level of Care Criteria set is intended to stand-alone. This makes it easy to find all the

relevant criteria for each level of care in one place. This layout causes a certain repetition,

however, since the General Criteria are repeated identically in each Level of Care Criteria set.

The numbering convention for the “Service Setting Criteria” consists of two-letters followed by

a number. The number represents the sequential placement of the criteria. For settings of care

that are specific to the treatment of mental or substance-related disorders, the second of the two

letters is an “M” or “S” respectively.

For example:

1. AM: The “A” represents “Acute Inpatient” while the “M” represents “Mental Disorders.”

2. AS: The “A” represents “Acute Inpatient” while the “S” represents “Substance-Related

Disorders.”

3. OM: The “O” represents “Traditional Outpatient” while again the “M” represents “Mental

Disorders.”

Listed below are the codes for each service setting.

A = Acute Inpatient

OB = 23 Hour Inpatient

S = Sub-Acute Inpatient

R = Respite Inpatient

TF = Therapeutic Foster Care

CR = Supervised Community Residential Care

P = Partial Hospital

I = Intensive Outpatient

CI = Outpatient Crisis Intervention

MT = Mobile Team

HH = Home Health Services

O = Traditional Outpatient

All one-letter codes are followed by either an “M” or an “S” to indicate a service setting specific

to:

Mental disorders (M)

Substance-related disorders (S)

The numbering convention for the “Treatment Setting Criteria” themselves, consists of the two-

letters described above followed by a number.


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Introduction


The numbering convention for the “Level of Care Criteria” starts with the two-letter designation

for the treatment setting followed by an “A,” , “C,” or “G” for Adult, Child and Adolescent, and

Geriatric respectively. This is followed by either “g,” “i,” or “c” for General, Treatment

Initiation or Treatment Continuation criteria. A number follows this letter. For example,

AM.C.g.1 refers to Acute inpatient Mental health treatment for Children, General criterion

number 1.

The Additional Clinical Criteria for Psychological Testing, Medical Detoxification, Eating

Disorders, Electroconvulsive Therapy and Applied Behavior Analysis follow a related, though

slightly different, format.


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Introduction


MAKING MEDICAL NECESSITY DETERMINATIONS

Whenever possible, medical necessity determinations should be made concurrently. The

information on which these determinations are made should be that information which is, or

reasonably should be, available to the clinician evaluating or treating the individual seeking or

receiving behavioral health care. Even when medical necessity determinations are made

retrospectively, they should be based on the information that was, or reasonably should have

been, available at the time the clinician was making treatment decisions.

Medical necessity determinations should always take into account the actual clinical treatment

resources available. If the appropriate level of care for a specific individual is not available

within a reasonable distance from the individual’s location, treatment at the next highest level of

care that is available should be authorized even though the individual’s clinical circumstances

will not meet all of the criteria for authorization at that level of care.

If the appropriate level of care for a specific individual is excluded from the benefit package then

treatment at the next highest level of care is not routinely authorized since the individual’s

clinical circumstances will not meet all of the criteria for authorization at a higher level. In such

circumstances, decisions about “flexing” benefits to provide an appropriate but otherwise

uncovered level of care will need to be made based on the individual account requirements.

Medical necessity determinations are clinical decisions whose purpose is to identify which health

care services are covered under the terms of a members’ contract with his/her health insurer or

health maintenance organization. Health care coverage always contains both clinical and non-

clinical exclusions and requirements.

This manual defines medically necessary services as those that are:

1. Intended to identify or treat a behavioral disorder or condition that causes pain or

suffering, threatens life, or results in illness as manifested by impairment in social,

occupational, scholastic, or role functioning.

2. Consistent with nationally accepted standards of medical practice.

3. Individualized, specific and consistent with the individual’s signs, symptoms, history and

diagnosis.

4. Reasonably expected to help restore or maintain the individual’s health or to improve or

prevent deterioration in the individual’s behavioral disorder or condition.

5. Not primarily for the convenience of the individual, provider or another party.

6. Provided in the least restrictive setting that balances safety, effectiveness and efficiency.

Coverage for medically necessary services may be eliminated or reduced because of non-clinical

factors such as benefit limits, coverage exclusions and pre-certification requirements. The

specifics of these non-clinical (administrative) factors are not described in this manual. Since

care management staff frequently make these administrative determinations (such as whether or

not a pre-certification requirement has been met, a benefit limit exceeded, or treatment at a

specific level of care is excluded), each criteria set in this manual addresses these non-clinical

factors with a requirement under “General Criteria” that states “No exclusionary criteria of the

health plan or benefit package are met.”


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Introduction


Even though an individual might meet criteria for treatment at a specific level of care, portions of

the treatment may be non-covered because specific criteria are not met for one or more treatment

days or sessions. Whether or not these “partial authorizations” are rendered will depend on an

array of factors including the specific provisions of the health care coverage contract or

arrangement.


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Introduction


PLAN SPECIFIC MODIFICATIONS

This manual is designed to focus on nationally accepted criteria. The need to make account or

plan specific modifications may arise. For example, many payers require that partial hospital

care be provided for six hours per day whereas others require only five hours. Organizations

needing to make such modifications can do so by developing plan-specific amendments to be

used in conjunction with the criteria contained in this manual.


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Introduction


CONTACTING THE MIHALIK GROUP

This Manual is reviewed on an ongoing basis and revised as appropriate. We welcome

comments and suggestions from professionals using the manual for ways to improve. You can

send your recommendations to:

The Mihalik Group, LLC

1300 West Belmont Avenue

Suite 500

Chicago, IL 60657

Telephone: (773) 929-4276

email: [email protected]


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SERVICE SETTING CRITERIA


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Service Setting Criteria


ABOUT THE SERVICE SETTING CRITERIA

Medical necessity decisions involve determining which service setting will best meet an

individual’s clinical needs. Behavioral health service settings can be differentiated based on six

characteristics. These characteristics are:

1. The numbers and types of behavioral health personnel available.

2. The degree to which the treatment setting provides for individual safety.

3. The intensity of treatment available.

4. The array of diagnostic and therapeutic modalities available.

5. The extent of support services (including support for ADLs) provided.

6. Access to medical care.

The following section categorizes behavioral health service settings into groups based on these

six characteristics. These service settings can be further refined based on characteristics of the

patient population served such as child, adolescent, adult, and geriatric or mental health vs.

substance use services. This Medical Necessity Manual for Behavioral Health is based on

recognizing the following service settings:

Acute Inpatient: Mental Health (page 12)

Acute Inpatient: Substance Related (page 14)

23-hour Inpatient Observation (page 16)

Sub-Acute Inpatient (Residential): Mental Health (page 18)

Sub-Acute Inpatient (Residential): Substance Related (page 20)

Respite Inpatient: Mental Health (page 23)

Therapeutic Foster Care (page 25)

Supervised Community Residential Care (page 27)

Partial Hospital: Mental Health (page 29)

Partial Hospital: Substance Related (page 31)

Intensive Outpatient: Mental Health (page 33)

Intensive Outpatient: Substance Related (page 35)

Outpatient Crisis Intervention (page 37)

Mobile Team (page 39)

Home Health Services (page 40)

Traditional Outpatient: Mental Health (page 42)

Traditional Outpatient: Substance Related (page 43)


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ACUTE INPATIENT: MENTAL HEALTH

An acute mental health inpatient treatment setting is the most restrictive and intensive setting

rendering care for individuals with mental health disorders. These settings provide continuous

(24 hours per day) skilled nursing care, daily medical care, the availability of psychiatrists and

physicians in other appropriate specialties 24 hours per day either on-call or in-house, and

intensive multi-modal, multidisciplinary assessment and treatment. Acute inpatient settings

provide the highest degree of individual safety using interventions up to and including physical

restraints, locked seclusion, and one-to-one (arm’s length) observation. Structured therapeutic

activities are available throughout the day and evening. In addition, acute inpatient settings can

provide individualized, unstructured therapeutic activities by professionals in a wide range of

disciplines to meet the individual’s clinical needs.

Behavioral Health Personnel

AM.1. Psychiatrists are available to provide treatment and consultation seven days per

week, twenty-four hours per day to meet the individual's clinical needs.

AM.2. Skilled psychiatric nursing staff provide nursing care seven days per week, twenty-

four hours per day.

AM.3. Treatment is provided by an appropriate multidisciplinary team of psychiatrists;

other behavioral health professionals licensed, certified, or registered to practice

independently; and by appropriately trained and currently competent behavioral

health staff under the direct supervision of behavioral health professionals licensed,

certified, or registered to practice independently.

AM.4. A psychiatrist oversees, and is actively involved in, treatment planning and the

provision of treatment.

Individual Safety

AM.5. Appropriately trained and currently competent staff provide supervision of patients

at any intensity, up to and including one-to-one observation.

AM.6. Facilities are available for the appropriate and safe use of restraints and seclusion, as

necessary, while maintaining individual dignity.

Behavioral Health Treatment Intensity

AM.7. The program operates twenty-four hours per day, seven days per week.

AM.8. Structured therapeutic activities are provided throughout the day and evening.

AM.9. Discharge planning begins on initiation of treatment.

Behavioral Health Diagnostic and Therapeutic Modalities

AM.10. A comprehensive array of diagnostic modalities is available.

AM.11. Policy and procedure require that, at a minimum, a focused behavioral health history

and mental status evaluation be completed on each individual prior to initiation of

treatment.

AM.12. Policy and procedure require that a psychiatrist complete a thorough behavioral

health history and mental status evaluation on each individual within twenty-four

hours of initiation of treatment.


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AM.13. Policy and procedure require that a qualified professional complete a screening

social assessment on each individual within twenty-four hours of initiation of

treatment that is used as the basis for determining whether or not a more thorough

social assessment is warranted.

AM.14. Multiple therapeutic modalities are provided including individual psychotherapy,

medication management, couples therapy, group psychotherapy, psycho-educational

groups and family therapy.

AM.15. Active treatment is provided according to an individualized plan directed toward

alleviating the signs, symptoms and/or impairment in functioning that necessitated

initiation of treatment.

AM.16. Individualized unstructured therapeutic activities can be provided in addition to

structured therapeutic activities to meet the individual’s specific clinical needs.

Supportive Services

AM.17. Full support for activities of daily living can be provided if clinically necessary.

AM.18. Staff are available to prompt, assist, or direct individuals, as appropriate, to

participate in therapeutic activities.

Medical Services

AM.19. Board certified or board eligible physicians, in a range of appropriate specialties, are

available to provide treatment and consultation seven days per week, twenty-four

hours per day to meet the individual's clinical needs.

AM.20. Policy and procedure require that a medical history and physical examination be

completed on each individual prior to, or at the time of, initiation of treatment.

AM.21. A comprehensive array of on-site medical services is available seven days per week,

twenty-four hours per day equivalent in scope to general hospital services.


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ACUTE INPATIENT: SUBSTANCE RELATED

An acute substance use inpatient treatment setting is the most restrictive and intensive setting

rendering care for individuals with substance use disorders. These settings provide continuous

(24 hours per day) skilled nursing care, daily medical care, the availability of psychiatrists,

physicians qualified in addiction medicine, and physicians in other appropriate specialties 24

hours per day either on-call or in-house, and intensive multi-modal, multidisciplinary assessment

and treatment. Acute inpatient settings provide the highest degree of individual safety using

interventions up to and including physical restraints, locked seclusion, and one-to-one (arm’s

length) observation. Structured therapeutic activities are available throughout the day and

evening. In addition, acute inpatient settings can provide individualized, unstructured

therapeutic activities by professionals in a wide range of disciplines to meet the individual’s

clinical needs.


AS.1. Psychiatrists and/or physicians qualified in addiction medicine are available to

provide treatment and consultation seven days per week, twenty-four hours per day

to meet the individual's clinical needs.

AS.2. Skilled nursing staff provide nursing care seven days per week, twenty-four hours

per day.

AS.3. Treatment is provided by an appropriate multidisciplinary team of psychiatrists

and/or physicians qualified in addiction medicine; other behavioral health

professionals licensed, certified, or registered to practice independently; and by

appropriately trained and currently competent behavioral health staff under the

direct supervision of behavioral health professionals licensed, certified, or registered

to practice independently.

AS.4. A psychiatrist or physician qualified in addiction medicine oversees, and is actively

involved in, treatment planning and the provision of treatment.

Individual Safety

AS.5. Appropriately trained and currently competent staff provide supervision of patients


AS.6. Facilities are available for the appropriate and safe use of restraints and seclusion, as



AS.7. The program operates twenty-four hours per day, seven days per week.

AS.8. Structured therapeutic activities are provided throughout the day and evening.

AS.9. Discharge planning begins on initiation of treatment.


AS.10. A comprehensive array of diagnostic modalities is available.

AS.11. Policy and procedure require that, at a minimum, a focused addictions and

behavioral health history and mental status evaluation be completed on each

individual prior to initiation of treatment.


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AS.12. Policy and procedure require that a physician qualified in addiction medicine or

psychiatrist complete a thorough addictions history and mental status evaluation on

each individual within twenty-four hours of initiation of treatment.

AS.13. Policy and procedure require that a psychiatrist complete a thorough behavioral


hours of initiation of treatment if warranted based on the results of the focused

behavioral health history and mental status evaluation completed prior to initiation

of treatment.

AS.14. Policy and procedure require that a qualified professional complete a screening




AS.15. Multiple therapeutic modalities are provided including individual psychotherapy,



AS.16. Active treatment is provided according to an individualized plan directed toward

alleviating the signs, symptoms and/or impairment in functioning that necessitated


AS.17. Individualized unstructured therapeutic activities can be provided in addition to


Supportive Services

AS.18. Full support for activities of daily living can be provided if clinically necessary.

AS.19. Staff are available to prompt, assist, or direct individuals, as appropriate, to


Medical Services

AS.20. Board certified or board eligible physicians, in a range of appropriate specialties, are



AS.21. Policy and procedure require that a medical history and physical examination be


AS.22. A comprehensive array of medical diagnostic and treatment services is available

seven days per week, twenty-four hours per day equivalent in scope to general

hospital services.


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23-HOUR INPATIENT OBSERVATION

Twenty-three hour inpatient observation provides a setting as restrictive and intensive as an acute

mental health inpatient treatment setting. Individuals are admitted to 23-hour inpatient

observation when there is the possibility that the need for this level of care may resolve quickly

with intensive treatment, after a short period of observation or after additional information is

gathered. These settings provide continuous (24 hour per day) skilled nursing care, daily

medical care, the availability of psychiatrists and physicians in other appropriate specialties 24

hours per day either on-call or in-house, and intensive multi-modal, multidisciplinary assessment

and treatment. Twenty-three hour inpatient observation settings provide the highest degree of

individual safety using interventions up to and including physical restraints, locked seclusion,

and one-to-one (arm’s length) observation. Structured therapeutic activities are available

throughout the day and evening. In addition, 23-hour inpatient observation settings can provide

individualized, unstructured therapeutic activities by professionals in a wide range of disciplines

to meet the individual’s clinical needs.


OB.1. Psychiatrists are available to provide treatment and consultation seven days per

week, twenty-four hours per day to meet the individual's clinical needs.

OB.2. Skilled psychiatric nursing staff provide nursing care seven days per week, twenty-

four hours per day.

OB.3. A psychiatrist oversees, and is actively involved in, treatment planning and the


Individual Safety

OB.4. Appropriately trained and currently competent staff provide supervision of patients


OB.5. Facilities are available for the appropriate and safe use of restraints and seclusion, as



OB.6. The program operates twenty-four hours per day, seven days per week.


OB.7. A comprehensive array of diagnostic modalities is available.

OB.8. Policy and procedure require that a psychiatrist complete a behavioral health history

and mental status evaluation on each individual prior to initiation of treatment.

OB.9. Multiple therapeutic modalities are provided including individual psychotherapy,

medication management and family therapy.

Supportive Services

OB.10. Full support for activities of daily living can be provided if clinically necessary.

OB.11. Staff are available to prompt, assist, or direct individuals, as appropriate, to



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Medical Services

OB.12. Board certified or board eligible physicians, in a range of appropriate specialties, are



OB.13. Policy and procedure require that a medical history and physical examination be


OB.14. A comprehensive array of medical diagnostic and treatment services is available

seven days per week, twenty-four hours per day equivalent in scope to general

hospital services.


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SUB-ACUTE INPATIENT (RESIDENTIAL): MENTAL HEALTH

A sub-acute mental health inpatient treatment setting provides continuous (24 hours per day)

supervision by skilled staff who are directly supervised by professional nurses. Skilled nursing

and medical care are available each day. Psychiatrists and physicians in other appropriate

specialties are available on-call 24 hours per day. Multi-modal, multidisciplinary assessment and

treatment are provided though the intensity of therapeutic offerings may be less than in an acute

inpatient setting. Sub-acute inpatient (residential) settings provide a high degree of individual

safety using interventions up to and including one-to-one (arm’s length) observation. Some sub-

acute inpatient (residential) settings have the capability of applying restraints and using

seclusion. Structured therapeutic activities are available periodically throughout the day and

evening, consisting of a minimum of six hours. In addition, sub-acute inpatient (residential)

settings can provide individualized, unstructured therapeutic activities by professionals in a range

of disciplines to meet the individual’s clinical needs.


SM.1. Psychiatrists are available each day to provide treatment and consultation on a

regular basis to meet the individual’s clinical needs.

SM.2. Skilled psychiatric nursing staff provide nursing care on a regular daily basis, as

appropriate, to meet the individual’s clinical needs.

SM.3. Appropriately trained and currently competent direct-care residential staff under the

supervision of registered nurses provide individual supervision twenty-four hours

per day.

SM.4. Treatment is provided by an appropriate multidisciplinary team of psychiatrists;

other behavioral health professionals licensed, certified, or registered to practice

independently; and by appropriately trained and currently competent behavioral

health staff under the direct supervision of behavioral health professionals licensed,

certified, or registered to practice independently.

SM.5. A psychiatrist oversees, and is actively involved in, treatment planning and the


Individual Safety

SM.6. Appropriately trained and currently competent staff provide supervision of patients



SM.7. The program operates twenty-four hours per day, seven days per week.

SM.8. Structured therapeutic activities are provided periodically throughout the day and

evening, consisting of a minimum of six hours.

SM.9. Discharge planning begins on initiation of treatment.


SM.10. Diagnostic modalities may be limited in scope to those which do not require

complex equipment but include, at a minimum, those which can be performed by

interview, observation, pencil and paper instruments, and basic pathologic and

laboratory analysis.


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SM.11. Policy and procedure require that, at a minimum, a focused behavioral health history


treatment.

SM.12. Policy and procedure require that a psychiatrist complete a thorough behavioral



SM.13. Policy and procedure require that a qualified professional complete a screening




SM.14. Multiple therapeutic modalities are provided including individual psychotherapy,

medication management, group psychotherapy, psycho-educational groups and

family therapy.

SM.15. Active treatment is provided according to an individualized plan directed toward:

SM.15.1 Alleviating the signs, symptoms and/or impairment in functioning that

necessitated initiation of treatment.

OR

SM.15.2 Maintaining the current level of symptom remission and/or level of

functioning.

SM.16. Individualized unstructured therapeutic activities can be provided in addition to


Supportive Services

SM.17. A significant degree of support for activities of daily living can be provided if

clinically necessary.

SM.18. Staff are available to prompt, assist, or direct individuals, as appropriate, to


Medical Services

SM.19. Board certified or board eligible physicians, in a range of appropriate specialties, are

available to provide consultation seven days per week, twenty-four hours per day to

meet the individual’s clinical needs.

SM.20. Policy and procedure require that a medical history and physical examination be

completed on each individual prior to initiation of treatment.

SM.21. Medical diagnostic and treatment services may be limited in scope to the kinds of

services that can typically be provided in a medical outpatient setting, including at a

minimum:

SM.21.1 Daily specimen collection, including venipuncture and urine.

AND

SM.21.2 Off-site pathology and laboratory services.

SM.22. If not available on-site, formal arrangements exist for providing more extensive

medical services up to and including hospitalization.


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SUB-ACUTE INPATIENT (RESIDENTIAL): SUBSTANCE RELATED

A sub-acute substance use inpatient treatment setting provides continuous (24 hours per day)

supervision by skilled staff who are directly supervised by professional nurses. Skilled nursing

and medical care are available each day. Psychiatrists, physicians qualified in addiction

medicine, and physicians in other appropriate specialties are available on-call 24 hours per day.

Multi-modal, multidisciplinary assessment and treatment are provided though the intensity of

therapeutic offerings may be less than in an acute inpatient setting. Sub-acute inpatient

(residential) settings provide a high degree of individual safety using interventions up to and

including one-to-one (arm’s length) observation. Some sub-acute inpatient (residential) settings

have the capability of applying restraints and using seclusion. Structured therapeutic activities

are available periodically throughout the day and evening, consisting of a minimum of six hours.

In addition, sub-acute inpatient (residential) settings can provide individualized, unstructured

therapeutic activities by professionals in a range of disciplines to meet the individual’s clinical

needs.


SS.1. Psychiatrists and/or physicians qualified in addiction medicine are available each

day to provide treatment and consultation on a regular basis to meet the individual’s

clinical needs.

SS.2. Skilled nursing staff provide nursing care on a regular daily basis, as appropriate, to


SS.3. Appropriately trained and currently competent direct-care residential staff under the

supervision of registered nurses, provide individual supervision twenty-four hours

per day.

SS.4. Treatment is provided by an appropriate multidisciplinary team of psychiatrists

and/or physicians qualified in addiction medicine; other behavioral health

professionals licensed, certified, or registered to practice independently; and by


direct supervision of behavioral health practitioners licensed, certified, or registered


SS.5. A psychiatrist or physician qualified in addiction medicine oversees treatment

planning and the provision of treatment.

Individual Safety

SS.6. Appropriately trained and currently competent staff provide supervision of patients



SS.7. The program operates twenty-four hours per day, seven days per week.

SS.8. Structured therapeutic activities are provided periodically throughout the day and

evening, consisting of a minimum of six hours.

SS.9. Discharge planning begins on initiation of treatment.


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SS.10. Diagnostic modalities may be limited in scope to those which do not require




SS.11. Policy and procedure require that, at a minimum, a focused addictions and

behavioral health history and mental status evaluation be completed on each

individual prior to initiation of treatment.

SS.12. Policy and procedure require that a psychiatrist or physician qualified in addiction

medicine complete a thorough addictions history and mental status evaluation on

each individual within twenty-four hours of initiation of treatment.

SS.13. Policy and procedure require that a psychiatrist complete a thorough behavioral


hours of initiation of treatment if warranted based on the results of the focused


of treatment.

SS.14. Policy and procedure require that a qualified professional complete a screening




SS.15. Multiple therapeutic modalities are provided including individual psychotherapy,

medication management, group psychotherapy, psycho-educational groups and

family therapy.

SS.16. Active treatment is provided according to an individualized plan directed toward:

SS.16.1 Alleviating the signs, symptoms and/or impairment in functioning that


OR

SS.16.2 Maintaining the current level of symptom remission and/or level of

functioning.

SS.17. Individualized unstructured therapeutic activities can be provided in addition to


Supportive Services

SS.18. A moderate degree of support for activities of daily living can be provided if


SS.19. Staff are available to prompt, assist, or direct individuals, as appropriate, to


Medical Services

SS.20. Board certified or board eligible physicians, in a range of appropriate specialties, are



SS.21. Policy and procedure require that a medical history and physical examination be



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SS.22. Medical diagnostic and treatment services may be limited in scope to the kinds of

services that can typically be provided in a medical outpatient setting, including at a

minimum:

SS.22.1 Daily specimen collection, including venipuncture and urine.

AND

SS.22.2 Off-site pathology and laboratory services.

SS.23. If not available on-site, formal arrangements exist for providing more extensive



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RESPITE INPATIENT: MENTAL HEALTH

Respite services exist as part of the continuum between the more structured, restrictive sub-acute

inpatient (residential) setting, and the usually lengthier residential setting. Respite services are

generally used to contain or allay crises for individuals, reducing the likelihood of acute inpatient

treatment. Respite services can be used to provide a temporary home-like environment for

individuals who may be psychiatrically stable but whose condition may be threatened by a return

to an inadequate living situation or homelessness. Respite services may be used as part of a

planned intervention for individuals with chronic mental illness, where occasional planned

respite stays may help maintain the stability of a living situation. Respite services can also offer

a temporary retreat when unanticipated changes, increased tension, or conflict threaten the stable

functioning of an individual residing in a usually stable environment.

A respite mental health inpatient setting provides continuous (24 hours per day) supervision by

skilled staff who are directly supervised by licensed behavioral health professionals. Skilled

nursing and medical care are available each day. Psychiatrists and physicians in other

appropriate specialties are available on-call 24 hours per day. Multi-modal, multidisciplinary

assessment and treatment are provided though the intensity of therapeutic offerings is less than in

an acute inpatient setting. Respite settings are not capable of providing a high degree of

individual safety. Patients must not be a danger to themselves or others. Respite settings can

provide individualized, unstructured therapeutic activities by professionals in a range of

disciplines to meet the individual’s clinical needs.


RM.1. Psychiatrists are available each day to provide treatment and consultation on a

regular basis to meet the individual’s clinical needs.

RM.2. Appropriately trained and currently competent direct-care residential staff under the

supervision of licensed behavioral health professionals provide individual

supervision twenty-four hours per day.

RM.3. A psychiatrist oversees, and is actively involved in, treatment planning and the


Individual Safety

RM.4. A minimal to moderate degree of safety can be assured based on the degree of staff

supervision.


RM.5. The program operates twenty-four hours per day, seven days per week.

RM.6. Access to behavioral health treatment services at any level of care up to and

including day treatment can be provided while maintaining the individual in respite

care.

RM.7. Discharge planning begins on initiation of respite care.


RM.8. Diagnostic modalities may be limited in scope to those which do not require



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RM.9. Policy and procedure require that, at a minimum, a focused behavioral health history


treatment.

RM.10. Policy and procedure require that a psychiatrist complete a thorough behavioral



RM.11. Policy and procedure require that a qualified professional complete a screening




RM.12. Active treatment is provided according to an individualized plan directed toward:

RM.12.1 Alleviating the signs, symptoms and/or impairment in functioning that


OR

RM.12.2 Maintaining the current level of symptom remission and/or level of

functioning.

RM.13. Individualized unstructured therapeutic activities can be provided in addition to


Supportive Services

RM.14. Staff provide training and skill building in activities of daily living, functioning in

the community, and accessing community resources.

RM.15. Staff can assist with problem solving, and provide counseling, behavior modeling

and mentoring.

RM.16. A significant degree of support for activities of daily living can be provided if


RM.17. Staff are available to prompt, assist, or direct individuals, as appropriate, to


Medical Services

RM.18. Board certified or board eligible physicians, in a range of appropriate specialties, are



RM.19. Policy and procedure require that a medical history and physical examination be

completed on each individual prior to initiation of treatment.

RM.20. If not available on-site, formal arrangements exist for providing more extensive



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THERAPEUTIC FOSTER CARE

The purpose of therapeutic foster care is to maintain a child or adolescent in a controlled home

environment in lieu of, or following discharge from, acute inpatient, sub-acute inpatient

(residential) or 23- hour inpatient observation while preparing the child or adolescent for a

permanent placement. In general, successful placement in therapeutic foster care requires that

the child or adolescent demonstrate higher social, scholastic and role functioning than is

necessary for placement in a supervised community residence. Children and adolescents placed

in therapeutic foster care must have the ability to follow rules and accept supervision from

surrogate parents. Typically, individuals are placed in this setting because their home

environment is not able to provide appropriate or adequate supervision. Therapeutic foster care

placements do not provide an individual’s primary behavioral health treatment but assist in

carrying out home-based portions of a treatment plan especially related to activities of daily

living and socialization.


TF.1. Behavioral health personnel are not available on site.

TF.2. Staff of the agency overseeing the therapeutic foster placement are available as

resources for the foster parents and foster child.

Individual Safety

TF.3. A moderate degree of safety can be assured due to the presence of foster parents.


TF.4. Adequately trained foster parents are available 24 hours per day seven days per

week and provide a safe environment and a setting that supports professional

treatment interventions.

TF.5. Access to out-of-home behavioral health treatment services at any level of care up

to and including day treatment and 23-hour inpatient observation can be provided

while maintaining the individual in the home.


TF.6. Diagnostic modalities are not available in the foster home itself.

TF.7. Foster parents provide a corrective parental experience including crisis intervention,

behavior management, counseling, behavior modeling and mentoring.

TF.8. Foster parents implement the home-based component of an individualized plan of

active treatment directed toward:

TF.8.1 Alleviating the signs, symptoms and/or impairment in functioning that


OR

TF.8.2 Maintaining the current level of symptom remission and/or level of

functioning.

Supportive Services

TF.9. A significant degree of support for activities of daily living can be provided if



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TF.10. Foster parents prompt, assist, or direct the individual, as appropriate, to participate

in therapeutic activities.

Medical Services

TF.11. Access to medical services is equivalent to what is available from a private home.


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SUPERVISED COMMUNITY RESIDENTIAL CARE

The purpose of supervised community residential care is to provide support and supervision

sufficient to maintain an individual in the community in lieu of, or following discharge from,

acute inpatient, sub-acute inpatient (residential) or 23-hour inpatient observation while preparing

the individual to function independently or in a less supervised and supportive environment. The

intensity of the supervision varies, as do the specific living arrangements. Staff may be available

on site 24 hours per day or only for a portion of each day but be available on-call the remainder

of the time. The living arrangements can include apartments that house two or three individuals

or group homes serving a larger population. In general supervised community residences do not

provide an individual’s primary behavioral health treatment but assist in carrying out specific

portions of a treatment plan especially related to activities of daily living and socialization.

Supervised community residential care settings include residential crisis intervention units,

supervised apartments, group homes, and halfway houses serving a limited number of

individuals in a home-like setting.


CR.1. Appropriately trained and currently competent direct-care residential staff under the

supervision of appropriate behavioral health professionals licensed, certified or

registered to practice independently provide individual supervision for all or part of

each day.

CR.2. Skilled psychiatric nursing staff may be available to provide nursing care on a

regular basis, as appropriate, to meet the individual’s clinical needs.

CR.3. Arrangements exist for psychiatrists to provide consultation as needed to meet the

individual’s clinical needs.

CR.4. A behavioral health professional, licensed, certified or registered to practice

independently oversees treatment planning and the provision of treatment.

Individual Safety

CR.5. A minimal to moderate degree of safety can be assured based on the degree of staff

supervision and the specific living arrangements.


CR.6. Staff are available on site or on call 24 hours per day seven days per week.

CR.7. Access to behavioral health treatment services, at any level of care up to and

including day treatment and 23-hour inpatient observation, can be provided while

maintaining the individual in the community residence.


CR.8. Diagnostic modalities are not typically available in the supported community

residential setting itself.

CR.9. Staff provide training and skill-building in activities of daily living, functioning in

the community, and accessing community resources.

CR.10. Staff can assist with problem solving, and provide counseling, behavior modeling

and mentoring.


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CR.11. Staff implement the residential component of an individualized plan of active

treatment directed toward:

CR.11.1 Alleviating the signs, symptoms and/or impairment in functioning that


OR

CR.11.2 Maintaining the current level of symptom remission and/or level of

functioning.

Supportive Services

CR.12. A significant degree of support for activities of daily living can be provided if


CR.13. Staff are available to prompt, assist, or direct individuals, as appropriate, to


Medical Services

CR.14. Access to medical services is equivalent to what is available from a private home.


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PARTIAL HOSPITAL: MENTAL HEALTH

Partial hospital is an intensive, structured setting providing medically supervised diagnostic and

therapeutic services. Partial hospital programs operate five to six hours per day, five or more

days per week. The number of days per week an individual participates in partial hospital is

based on clinical need but the program must be available to provide services to those individuals

who require treatment five days per week. During program hours, partial hospital programs

provide services equivalent in intensity and scope to those provided in acute inpatient settings.

Partial hospital programs provide skilled nursing care and the availability of daily psychiatric

care. A multi-disciplinary team of professionals provides integrated, multi-modal assessment

and therapeutic services. Staff can provide line of sight observation for those individuals who

require this level of intervention to assure their safety. Structured therapeutic activities are

available during all program hours. In addition, partial hospital programs can provide

individualized, unstructured therapeutic activities by professionals in a wide range of disciplines

to meet the individual’s clinical needs.


PM.1. Psychiatrists are available each program day to provide treatment and consultation

on a regular basis to meet the individual’s clinical needs.

PM.2. Skilled psychiatric nursing staff provide nursing care each program day.

PM.3. Treatment is provided by an appropriate multidisciplinary team of behavioral health

professionals licensed, certified, or registered to practice independently and by




PM.4. A psychiatrist oversees treatment planning and the provision of treatment.

Individual Safety

PM.5. During program hours, appropriately trained and currently competent staff provide

supervision of patients at any intensity, up to and including line-of-sight

observation.

PM.6. Partial hospital programs provide no direct assurance of individual safety outside of

normal program hours.


PM.7. The program operates five or six hours per day1, five or more days per week.

PM.8. Structured therapeutic activities are provided during all program hours.

PM.9. Discharge planning begins on initiation of treatment.


PM.10. Diagnostic modalities may be limited in scope to those that can be performed by

interview, observation, pencil and paper instruments and basic pathologic and


1 Based on specific contractual or regulatory requirements partial hospital programs may operate for more or fewer

hours per program day.


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PM.11. Policy and procedure require that, at a minimum, a focused behavioral health history


treatment.

PM.12. Policy and procedure require that a psychiatrist complete a thorough behavioral

health history and mental status evaluation on each individual within one treatment

day of initiation of treatment.

PM.13. Multiple therapeutic modalities are provided including individual psychotherapy,



PM.14. Active treatment is provided according to an individualized plan directed toward:

PM.14.1 Alleviating the signs, symptoms and/or impairment in functioning that


OR

PM.14.2 Maintaining the current level of symptom remission and/or level of

functioning.

PM.15. Individualized unstructured therapeutic activities can be provided in addition to


Supportive Services

PM.16. Minimal support for activities of daily living is provided.

PM.17. Staff are available to prompt, assist, or direct individuals, as appropriate, to


Medical Services

PM.18. Policy and procedure require that an appropriate licensed, certified, or registered

clinician complete a screening medical history within one treatment day of initiation

of treatment.

PM.19. Physicians and medical services are typically not available on site but formal

arrangements exist for providing medical care.


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PARTIAL HOSPITAL: SUBSTANCE RELATED

Partial hospital is an intensive, structured setting providing medically supervised diagnostic and

therapeutic services. Partial hospital programs operate five to six hours per day, five or more

days per week. The number of days per week an individual participates in partial hospital is

based on clinical need but the program must be available to provide services to those individuals

who require treatment five days per week. During program hours, partial hospital programs

provide services equivalent in intensity and scope to those provided in acute inpatient settings.

Partial hospital programs provide skilled nursing care and the availability of daily psychiatric

and addiction medicine care. A multi-disciplinary team of professionals provides integrated,

multi-modal assessment and therapeutic services. Staff can provide line of sight observation for

those individuals who require this level of intervention to assure their safety. Structured

therapeutic activities are available during all program hours. In addition, partial hospital

programs can provide individualized, unstructured therapeutic activities by professionals in a

wide range of disciplines to meet the individual’s clinical needs.


PS.1. Psychiatrists and/or physicians qualified in addiction medicine are available each

program day to provide treatment and consultation on a regular basis to meet the

individual’s clinical needs.

PS.2. Skilled nursing staff provide nursing each program day.

PS.3. Treatment is provided by an appropriate multidisciplinary team of behavioral health





PS.4. A psychiatrist or physician qualified in addiction medicine oversees treatment

planning and the provision of treatment.

Individual Safety

PS.5. During program hours, appropriately trained and currently competent staff provide

supervision of patients at any intensity, up to and including line-of-sight

observation.

PS.6. Partial hospital programs provide no direct assurance of individual safety outside of

normal program hours.


PS.7. The program operates five to six hours per day2, five or more days per week.

PS.8. Structured therapeutic activities are provided during all program hours.

PS.9. Discharge planning begins on initiation of treatment.

2 Based on specific contractual or regulatory requirements partial hospital programs may operate for more or fewer

hours per program day.


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PS.10. Diagnostic modalities may be limited in scope to those that can be performed by

interview, observation, pencil and paper instruments and basic pathologic and


PS.11. Policy and procedure require that, at a minimum, a focused behavioral health history


treatment.

PS.12. Policy and procedure require that a physician qualified in addiction medicine or

psychiatrist complete a thorough addictions history and mental status evaluation on

each individual within one treatment day of initiation of treatment.

PS.13. Policy and procedure require that a psychiatrist complete a thorough behavioral

health history and mental status evaluation on each individual within one treatment

day of initiation of treatment if warranted based on the results of the focused


of treatment.

PS.14. Multiple therapeutic modalities are provided including individual psychotherapy,



PS.15. Active treatment is provided according to an individualized plan directed toward:

PS.15.1 Alleviating the signs, symptoms and/or impairment in functioning that


OR

PS.15.2 Maintaining the current level of symptom remission and/or level of

functioning.

PS.16. Individualized unstructured therapeutic activities can be provided in addition to


Supportive Services

PS.17. Minimal support for activities of daily living is provided.

PS.18. Staff are available to prompt, assist, or direct individuals, as appropriate, to


Medical Services

PS.19. Policy and procedure require that an appropriate licensed, certified, or registered

clinician complete a screening medical history within one treatment day of initiation

of treatment.

PS.20. Physicians and medical services are typically not available on site but formal

arrangements exist for providing medical care.


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INTENSIVE OUTPATIENT: MENTAL HEALTH

An intensive outpatient program is a structured setting providing multidisciplinary diagnostic

and therapeutic services. Intensive outpatient programs operate at least three hours per day, three

or more days per week. The number of days per week an individual participates in intensive

outpatient is based on clinical need. Although therapeutic interventions are provided by a

multidisciplinary team, nursing care may not be available. Intensive outpatient programs need

not be medically supervised. Such programs, must however, have a formal arrangement for

psychiatric consultation as needed. Structured therapeutic activities are available during all

program hours. In addition, intensive outpatient programs can provide individualized,

unstructured therapeutic activities equivalent to those typically delivered in office-based settings

including individual psychotherapy, couples therapy, group psychotherapy, psycho-educational

groups and family therapy. Medication management may be provided.


IM.1. Psychiatrists are available as needed to provide consultation.

IM.2. Treatment is provided by an appropriate multidisciplinary team of behavioral health





IM.3. A behavioral health professional licensed, certified or registered to practice

independently oversees treatment planning and the provision of treatment.

Individual Safety

IM.4. There is minimal assurance of individual safety.


IM.5. The program operates three or more hours per day, three or more days per week.

IM.6. Structured therapeutic activities are provided during all program hours.

IM.7. Discharge planning begins on initiation of treatment.


IM.8. Diagnostic modalities may be limited in scope to those that can be performed by

interview, observation, and pencil and paper instruments.

IM.9. A behavioral health history and mental status evaluation completed by a behavioral

health professional licensed, certified, or registered to practice independently are the

basis for formulating the initial treatment plan.

IM.10. Multiple therapeutic modalities are provided such as individual psychotherapy,

couples therapy, group psychotherapy, psycho-educational groups and family

therapy. Medication management may be provided.

IM.11. Active treatment is provided according to an individualized plan directed toward:

IM.11.1 Alleviating the signs, symptoms and/or impairment in functioning that


OR


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IM.11.2 Maintaining the current level of symptom remission and/or level of

functioning.

IM.12. Individualized unstructured therapeutic activities can be provided in addition to


Supportive Services

IM.13. Minimal support for activities of daily living is provided.

Medical Services

IM.14. Formal arrangements for medical services may not be available through the

program.


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INTENSIVE OUTPATIENT: SUBSTANCE RELATED

An intensive outpatient program is a structured setting providing multidisciplinary diagnostic

and therapeutic services. Intensive outpatient programs operate at least three hours per day, three

or more days per week. The number of days per week an individual participates in intensive

outpatient is based on clinical need. Although therapeutic interventions are provided by a

multidisciplinary team, nursing care may not be available. Intensive outpatient programs need

not be medically supervised. Such programs, must however, have a formal arrangement for

psychiatric and/or addiction medicine consultation as needed. Nursing and/or medical care must

be available in those intensive outpatient programs that provide detoxification. Structured

therapeutic activities are available during all program hours. In addition, intensive outpatient

programs can provide individualized, unstructured therapeutic activities equivalent to those

typically delivered in office-based settings including individual psychotherapy, couples therapy,

group psychotherapy, psycho-educational groups and family therapy. Medication management

may be provided. Time spent in community-based self-help activities such as Alcoholics

Anonymous, Narcotics Anonymous, and so forth does not count toward intensive outpatient

program hours.


IS.1. Psychiatrists and/or physicians qualified in addiction medicine are available as

needed to provide consultation.

IS.2. Treatment is provided by an appropriate multidisciplinary team of behavioral health





IS.3. A behavioral health professional licensed, certified, or registered to practice

independently, oversees treatment planning and the provision of treatment.

Individual Safety

IS.4. There is minimal assurance of individual safety.


IS.5. The program operates three or more hours per day, three or more days per week.

IS.6. Structured therapeutic activities are provided during all program hours.

IS.7. Discharge planning begins on initiation of treatment.


IS.8. Diagnostic modalities may be limited in scope to those that can be performed by


IS.9. A behavioral health and addictions history and mental status evaluation completed

by a behavioral health professional licensed, certified, or registered to practice

independently are the basis for formulating the initial treatment plan.

IS.10. Multiple therapeutic modalities are provided such as individual psychotherapy,

couples therapy, group psychotherapy, psycho-educational groups and family

therapy. Medication management may be provided.


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IS.11. Active treatment is provided according to an individualized plan directed toward:

IS.11.1 Alleviating the signs, symptoms and/or impairment in functioning that


OR

IS.11.2 Maintaining the current level of symptom remission and/or level of

functioning.

IS.12. Individualized unstructured therapeutic activities can be provided in addition to


Supportive Services

IS.13. Minimal support for activities of daily living is provided.

Medical Services

IS.14. Formal arrangements for medical services may not be available through the

program.


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OUTPATIENT CRISIS INTERVENTION

Outpatient crisis intervention and stabilization services consist of unstructured, intensive

outpatient services designed to provide the intensity and types of services necessary to diffuse a

crisis and facilitate entry into more structured and formalized care. These services can include

family stabilization, short term services designed to permit children and adolescents to remain at

home rather than being admitted to acute or sub acute inpatient services, supervised community

residential services or therapeutic foster care. Services at this level of care may be provided as a

component of a structured facility-based treatment program or may be provided in an outpatient

treatment setting that has the capacity to respond quickly to provide intensive, individualized

treatment.


CI.1. Treatment is provided by one or more behavioral health professionals licensed,

certified, or registered to practice independently and experienced in crisis

intervention and stabilization.

CI.2. If outpatient crisis intervention and stabilization services are not being provided by a

psychiatrist, formal arrangements exist for consulting with or involving a

psychiatrist in the intervention.

Individual Safety

CI.3. There is minimal assurance of individual safety other than when the individual is

face-to-face with a behavioral health professional.


CI.4. The intensity and duration of treatment are driven by individual need. Crisis

intervention and stabilization services are short term and typically more intensive

than traditional outpatient services in terms of frequency of individual sessions,

length of individual sessions or both.


CI.5. A focused behavioral health history and mental status evaluation and other

assessments as appropriate (such as family or couples assessments) completed by a

behavioral health professional licensed, certified or registered to practice

independently are the basis for formulating the intervention and subsequent

treatment plan.

CI.6. Diagnostic modalities may be limited in scope to those that can be performed by

interview and observation.

CI.7. Multiple therapeutic modalities are provided as needed such as medication

administration and management, crisis-oriented individual psychotherapy, couples

therapy, and/or family therapy.

CI.8. Focused crisis-intervention services are provided which are directed toward

stabilizing the immediate crisis and alleviating the signs, symptoms and/or

impairment in functioning that necessitated initiation of treatment.


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Supportive Services

CI.9. No support for activities of daily living is provided.

Medical Services

CI.10. Formal arrangements for medical services need not be available.


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MOBILE TEAM

A mobile team provides on-site assessment and crisis intervention and stabilization services 24

hours per day seven days per week. A minimum of two behavioral health professionals provide

unstructured, intensive services to diffuse a crisis and facilitate entry into more structured and

formalized care.


MT.1. Treatment is provided by an appropriate multidisciplinary team of consisting of one

or more behavioral health professionals licensed, certified, or registered to practice

independently who may be assisted by one or more appropriately trained and

currently competent behavioral health staff under the direct supervision of

behavioral health professionals licensed, certified, or registered to practice

independently.

MT.2. A psychiatrist provides services as a member of and/or supervises the mobile team.

Individual Safety

MT.3. There is minimal assurance of individual safety other than when the individual is



MT.4. The intensity and duration of treatment are driven by individual need. Mobile teams

typically provide on-site crisis intervention and stabilization services, which are

short term but intensive.


MT.5. A focused behavioral health history and mental status evaluation and other

assessments as appropriate (such as family or couples assessments) completed by a

behavioral health professional licensed, certified, or registered to practice

independently are the basis for formulating the intervention and subsequent

treatment plan.

MT.6. Diagnostic modalities may be limited in scope to those that can be performed by

interview and observation.

MT.7. Multiple therapeutic modalities are provided as needed such as medication

administration and management, crisis-oriented individual psychotherapy, couples

therapy, and/or family therapy.

MT.8. Focused in-home crisis-intervention services are provided which are directed toward

stabilizing the immediate crisis and alleviating the signs, symptoms and/or

impairment in functioning that necessitated initiation of treatment.

Supportive Services

MT.9. No support for activities of daily living is provided.

Medical Services

MT.10. Urgent or emergent medical services can be facilitated by arranging for ambulance

transportation to a medical facility.


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HOME HEALTH SERVICES

Home health services encompass a diverse array of services spanning wide ranges of intensity

and duration. Home health services can be provided to individuals who are unable or unwilling

to leave home. Home health services may be time-limited and focused on improving a specific

problem or symptom or they may represent the most effective strategy for delivering

maintenance treatment (such as the periodic administration of long-acting antipsychotic

medications).


HH.1. Treatment is provided by one or more behavioral health professionals licensed,

certified, or registered to practice independently who may be assisted by




Individual Safety

HH.2. There is minimal assurance of individual safety other than when the individual is



HH.3. The intensity and duration of treatment are driven by individual need.


HH.4. A behavioral health history and mental status evaluation and other assessments as

appropriate (such as family or couples assessments) completed by a behavioral

health professional licensed, certified, or registered to practice independently are the

basis for formulating the intervention and subsequent treatment plan.

HH.5. Diagnostic modalities may be limited in scope to those that can be performed by



HH.6. Multiple therapeutic modalities are provided as needed such as medication

administration and management, individual psychotherapy, couples therapy, family

therapy, skill building, mentoring, and family education and training;

HH.7. Active treatment is provided according to an individualized plan directed toward:

HH.7.1 Alleviating the signs, symptoms and/or impairment in functioning that

necessitated initiation of treatment; or

HH.7.2 Maintaining the current level of symptom remission and/or level of

functioning.

HH.8. Individualized therapeutic activities can be developed to meet the individual’s

clinical needs.

Supportive Services

HH.9. Moderate support for activities of daily living can be provided, if necessary.

HH.10. Staff are available to prompt, assist, or direct individuals, as appropriate, to



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Medical Services

HH.11. Urgent or emergent medical services can be facilitated by arranging for ambulance

transportation to a medical facility.


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TRADITIONAL OUTPATIENT: MENTAL HEALTH

Traditional outpatient services are typically rendered in an office or clinic setting and consist of

individual, group, family, and couples assessment, counseling or psychotherapy and individual

medication management.


OM.1. Treatment is provided by behavioral health professionals licensed, certified or

registered to practice independently.

Individual Safety

OM.2. There is minimal assurance of safety for the individual or others.


OM.3. Typically, one service per day is provided though the intensity and duration of

treatment is driven by individual need.


OM.4. Diagnostic modalities are limited in scope to those that can be performed by


OM.5. A behavioral health history and mental status evaluation completed by a behavioral

health practitioner licensed, certified or registered to practice independently are the

basis for formulating treatment recommendations.

OM.6. Multiple therapeutic modalities can be provided at this level including individual

psychotherapy, medication management, couples psychotherapy, family

psychotherapy and group psychotherapy. Individual sites may provide only one, or

a limited number, of these modalities.

OM.7. Active treatment is provided according to an individualized plan directed toward:

OM.7.1 Alleviating the signs, symptoms and/or impairment in functioning that


OR

OM.7.2 Maintaining the current level of symptom remission and/or level of

functioning.

Supportive Services

OM.8. No support for activities of daily living is provided.

Medical Services

OM.9. There is no formal arrangement for facilitating access to medical services.


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TRADITIONAL OUTPATIENT: SUBSTANCE RELATED

Traditional outpatient services are typically rendered in an office or clinic setting and consist of

individual, group, family, and couples assessment, counseling or psychotherapy and individual

medication management.


OS.1. Treatment is provided by behavioral health professionals licensed, certified or

registered to practice independently.

Individual Safety

OS.2. There is minimal assurance of safety for the individual or others.


OS.3. Typically one service per day is provided though the intensity and duration of

treatment is driven by individual need.


OS.4. Diagnostic modalities are limited in scope to those that can be performed by


OS.5. An addictions and behavioral health history and mental status evaluation completed

by a behavioral health practitioner licensed, certified or registered to practice

independently are the basis for formulating treatment recommendations.

OS.6. Multiple therapeutic modalities can be provided at this level including individual

psychotherapy, medication management, couples psychotherapy, family

psychotherapy and group psychotherapy. Individual sites may provide only one, or

a limited number, of these modalities.

OS.7. Active treatment is provided according to an individualized plan directed toward:

OS.7.1 Alleviating the signs, symptoms and/or impairment in functioning that


OR

OS.7.2 Maintaining the current level of symptom remission and/or level of

functioning.

Supportive Services

OS.8. No support for activities of daily living is provided.

Medical Services

OS.9. There is no formal arrangement for facilitating access to medical services.


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ADULT

LEVEL OF CARE CRITERIA


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Adult Level of Care Criteria


ACUTE INPATIENT TREATMENT: MENTAL HEALTH

General Criteria

All of the following General Criteria are required throughout the episode of care.

AM.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

AM.A.g.2. The services must be individualized, specific, and consistent with the individual’s

signs, symptoms, history, and diagnosis.

AM.A.g.3. The services must be reasonably expected to help restore or maintain the

individual’s health, improve or prevent deterioration of the individual’s behavioral

disorder or condition, or delay progression in a clinically meaningful way of a

behavioral health disorder or condition characterized by a progressively

deteriorating course when that disorder or condition is the focus of treatment for this

episode of care.

AM.A.g.4. The individual complies with the essential elements of treatment.

AM.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

AM.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,

incarceration, or other legal consequences.

AM.A.g.7. The services are not predominantly domiciliary or custodial.

AM.A.g.8. No exclusionary criteria of the health plan or benefit package are met.

Treatment Initiation Criteria

All of the following Treatment Initiation Criteria are required.

AM.A.i.1. Based on a behavioral health history and mental status evaluation completed by a

psychiatrist or by a behavioral health professional licensed, certified, or registered to

practice independently and reviewed by a psychiatrist prior to initiation of

treatment, the individual is diagnosed as having, or there is strong presumptive

evidence that the individual has a diagnosis of, a mental disorder or condition

according to the most recent version of the Diagnostic and Statistical Manual of

Mental Disorders that requires, and is likely to respond to, professional therapeutic

intervention.

AM.A.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical

condition is primarily responsible for the symptoms or behaviors necessitating

treatment in this setting.

AM.A.i.3. As a result of the mental disorder or condition:

AM.A.i.3.1 The individual’s level of functioning has deteriorated such that the

individual is now a clear and present danger to self, a clear and


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present danger to others, or unable to provide for basic self-care needs

resulting in impending, serious self-harm.

OR

AM.A.i.3.2 The individual requires an unusual or medically dangerous form of

somatic therapy that is not safe to be instituted without the availability

of immediate medical care.

AM.A.i.4. Continuous skilled behavioral health nursing care, not just twenty-four hour per day

supervision by trained personnel, and the availability of immediate medical care are

needed to observe, treat, or potentially contain the individual because:

AM.A.i.4.1 The individual is likely to require restraints or seclusion.

OR

AM.A.i.4.2 There is a significant probability that the individual will experience

medically dangerous side effects from prescribed psychotropic

medications.

OR

AM.A.i.4.3 The individual is, or there is a significant probability that the

individual will become, acutely seriously medically compromised as a

consequence of the mental disorder.

AM.A.i.5. If the services being proposed have been attempted previously without significant

therapeutic benefit, there is a clinically credible rationale for why those same

services could be effective now.

AM.A.i.6. The place of service meets the Service Setting Criteria for Acute Inpatient: Mental

Health as described on page 12.

Treatment Continuation Criteria

All of the following Treatment Continuation Criteria are required throughout the episode of care.

AM.A.c.1. The individual continues to meet the treatment initiation criteria each day that

services are provided at this level.

AM.A.c.2. There is an individualized plan of active, professionally directed treatment that

specifies the goals, interventions, time frames, and anticipated outcomes appropriate

to:

AM.A.c.2.1 Improve or prevent deterioration or delay progression in a clinically

meaningful way of the symptoms of, or impairment in functioning

resulting from, the mental disorder or condition that necessitated


AND


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AM.A.c.2.2 Address a co-morbid substance use disorder or condition, if one

exists.

AM.A.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge

plan, and criteria for discharge are clinically efficient, reasonable, and achievable in

the length of stay typically associated with treatment at this level.

AM.A.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

AM.A.c.5. There are daily progress notes by the treating psychiatrist and other appropriate staff

describing the therapeutic interventions rendered and the individual’s response.

AM.A.c.6. As appropriate, members of the individual’s social support system are involved in

the individual’s treatment.


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ACUTE INPATIENT TREATMENT: SUBSTANCE RELATED

General Criteria


AS.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

AS.A.g.2. The services must be individualized, specific, and consistent with the individual’s


AS.A.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

AS.A.g.4. The individual complies with the essential elements of treatment.

AS.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

AS.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


AS.A.g.7. The services are not predominantly domiciliary or custodial.

AS.A.g.8. No exclusionary criteria of the health plan or benefit package are met.



AS.A.i.1. Based on a behavioral health history and mental status evaluation completed by a

psychiatrist; physician qualified in addiction medicine; or by a behavioral health

professional licensed, certified, or registered to practice independently and reviewed

by a psychiatrist or physician qualified in addiction medicine prior to initiation of


evidence that the individual has a diagnosis of, a substance dependence disorder



intervention.

AS.A.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



AS.A.i.3. The individual is dependent on a class or classes and quantity or quantities of

substances requiring a medical detoxification (see Substance Use Requiring Medical

Detoxification on page 167).


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AS.A.i.4. Continuous skilled behavioral health nursing care, not just twenty-four hour per day


needed to observe or detoxify the individual because:

AS.A.i.4.1 The individual has a history of medically complicated detoxification

episodes.

OR

AS.A.i.4.2 The individual has unstable vital signs not treatable on an outpatient

basis.

OR

AS.A.i.4.3 The individual has a medical co-morbidity that significantly increases

the probability that the individual will become acutely seriously

medically compromised during the detoxification.

AS.A.i.5. The place of service meets the Service Setting Criteria for Acute Inpatient:

Substance Related as described on page 14.



AS.A.c.1. The individual continues to meet the treatment initiation criteria each day that


AS.A.c.2. There is an individualized plan of active, professionally directed treatment that

specifies goals, interventions, time frames, and anticipated outcomes appropriate to:

AS.A.c.2.1 Detoxify the individual from the substances requiring a medical

detoxification.

AND

AS.A.c.2.2 Address a co-morbid mental health disorder or condition, if one

exists.

AS.A.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



AS.A.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

AS.A.c.5. There are daily progress notes by the treating psychiatrist or physician qualified in

addiction medicine and other appropriate staff describing the therapeutic

interventions rendered and the individual’s response.

AS.A.c.6. As appropriate, members of the individual’s social support system are involved in



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General Criteria


OB.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

OB.A.g.2. The services must be individualized, specific, and consistent with the individual’s


OB.A.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

OB.A.g.4. The individual complies with the essential elements of treatment.

OB.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

OB.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


OB.A.g.7. The services are not predominantly domiciliary or custodial.

OB.A.g.8. No exclusionary criteria of the health plan or benefit package are met.



OB.A.i.1. Based on a behavioral health history and mental status evaluation completed by a





evidence that the individual has a diagnosis of, a mental or substance related

disorder or condition according to the most recent version of the Diagnostic and

Statistical Manual of Mental Disorders that requires, and is likely to respond to,

professional therapeutic intervention.

OB.A.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



OB.A.i.3. As a result of the mental or substance related disorder or condition:

OB.A.i.3.1 The individual’s level of functioning has deteriorated such that the



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OR

OB.A.i.3.2 The individual is dependent on a class or classes and quantity or

quantities of substances requiring a medical detoxification (see

Substance Use Requiring Medical Detoxification on page 167).

OB.A.i.4. Continuous skilled behavioral health nursing care, not just twenty-four hour per day


needed to observe, treat, or possibly contain the individual because:

OB.A.i.4.1 The individual is likely to require restraints or seclusion.

OR

OB.A.i.4.2 The individual has experienced, or there is a significant likelihood

that the individual will experience, unusually severe side effects from

prescribed psychotropic medications.

OR

OB.A.i.4.3 The individual has a history of medically complicated detoxification

episodes.

OR

OB.A.i.4.4 The individual has unstable vital signs not treatable on an outpatient

basis resulting from dependence on a class or classes and quantity or

quantities of substances requiring a medical detoxification.

OR

OB.A.i.4.5 The individual has a medical co-morbidity that significantly increases



OB.A.i.5. The individual’s presentation may stabilize, improve, or resolve making treatment at

a less intense level possible within 23 hours.

OB.A.i.6. The place of service meets the Service Setting Criteria for 23-hour Inpatient

Observation as described on page 16.

There are no Treatment Continuation Criteria for 23-hour Inpatient Observation. The

individual must be discharged or transitioned to another level of care.


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SUB-ACUTE INPATIENT (RESIDENTIAL) TREATMENT: MENTAL HEALTH

General Criteria


SM.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

SM.A.g.2. The services must be individualized, specific, and consistent with the individual’s


SM.A.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

SM.A.g.4. The individual complies with the essential elements of treatment.

SM.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

SM.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


SM.A.g.7. The services are not predominantly domiciliary or custodial.

SM.A.g.8. No exclusionary criteria of the health plan or benefit package are met.



SM.A.i.1. Based on a behavioral health history and mental status evaluation completed by a







intervention.

SM.A.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



SM.A.i.3. As a result of the mental disorder or condition, the individual’s level of functioning

has deteriorated such that the individual is now a clear and present danger to self, a

clear and present danger to others, or unable to provide for basic self-care needs



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SM.A.i.4. The individual is not capable of controlling behaviors or seeking professional help

and therefore requires treatment in a structured setting providing twenty-four hour

per day supervision by trained personnel.

SM.A.i.5. There is a substantial probability of initiation of acute inpatient treatment in the

absence of sub-acute inpatient (residential) treatment.

SM.A.i.6. If the services being proposed have been attempted previously without significant



SM.A.i.7. The place of service meets the Service Setting Criteria for Sub-Acute Inpatient

(Residential): Mental Health as described on page 18.



SM.A.c.1. The individual continues to meet the treatment initiation criteria each day that


SM.A.c.2. There is an individualized plan of active, professionally directed treatment that


to:

SM.A.c.2.1 Improve or prevent deterioration or delay progression in a clinically




AND

SM.A.c.2.2 Address a co-morbid substance use disorder or condition, if one

exists.

SM.A.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



SM.A.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

SM.A.c.5. There are daily progress notes by the treating psychiatrist and other appropriate staff


SM.A.c.6. As appropriate, members of the individual’s social support system are involved in



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SUB-ACUTE INPATIENT (RESIDENTIAL) TREATMENT: SUBSTANCE RELATED

General Criteria


SS.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

SS.A.g.2. The services must be individualized, specific, and consistent with the individual’s


SS.A.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

SS.A.g.4. The individual complies with the essential elements of treatment.

SS.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

SS.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


SS.A.g.7. The services are not predominantly domiciliary or custodial.

SS.A.g.8. No exclusionary criteria of the health plan or benefit package are met.



SS.A.i.1. Based on a behavioral health history and mental status evaluation completed by a








intervention.

SS.A.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



SS.A.i.3. If the services being proposed have been attempted previously without significant




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SS.A.i.4. The place of service meets the Service Setting Criteria for Sub-Acute Inpatient

(Residential): Substance Related as described on page 20.

One of the following Treatment Initiation Criteria is also required.

SS.A.i.5. The individual is dependent on a class or classes and quantity or quantities of



AND

SS.A.i.5.1 The individual has a psychiatric co-morbidity necessitating twenty-

four hour per day supervision by trained personnel (for example, the

individual is not reliably able to seek professional help should

problems arise during the detoxification).

OR

SS.A.i.5.2 The individual has a social co-morbidity that precludes an outpatient

detoxification.

SS.A.i.6. The individual is seriously medically compromised and risks significant acute

complications if substance use resumes and the individual is not capable of

controlling substance use when not in a structured setting with twenty-four hour per

day staff supervision.

SS.A.i.7. There is significant impairment in the individual’s social, occupational, scholastic or

role functioning as a result of the substance dependence and there is a clinically

credible rationale for why treatment in a structured setting with twenty-four hour per

day staff supervision will substantially reverse the impairment in social,

occupational, scholastic or role functioning.



SS.A.c.1. The individual continues to meet the treatment initiation criteria each day that


SS.A.c.2. There is an individualized plan of active, professionally directed treatment that


SS.A.c.2.1 Detoxify the individual from the substances requiring a medical

detoxification.

OR

SS.A.c.2.2 Improve or prevent deterioration or delay progression in a clinically


resulting from, the substance use disorder that necessitated initiation

of treatment.

AND


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SS.A.c.2.3 Address a co-morbid mental health disorder or condition, if one

exists.

SS.A.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



SS.A.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

SS.A.c.5. There are daily progress notes by the treating psychiatrist or physician qualified in



SS.A.c.6. As appropriate, members of the individual’s social support system are involved in



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RESPITE INPATIENT CARE: MENTAL HEALTH

General Criteria


RM.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

RM.A.g.2. The services must be individualized, specific, and consistent with the individual’s


RM.A.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

RM.A.g.4. The individual complies with the essential elements of treatment.

RM.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

RM.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


RM.A.g.7. The services are not predominantly domiciliary or custodial.

RM.A.g.8. No exclusionary criteria of the health plan or benefit package are met.



RM.A.i.1. Based on a behavioral health history and mental status evaluation completed by a







intervention.

RM.A.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



RM.A.i.3. Respite inpatient care combined with active behavioral health treatment can

stabilize or improve the individual’s social functioning permitting the individual to

live safely in the community, provide for basic self-care needs, participate in

behavioral health treatment, and cope with the sequelae of his/her behavioral health

disorder or condition.


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RM.A.i.4. The individual does not have adequate internal resources or an adequate external

support system to maintain functioning without the structure of respite inpatient

care.

RM.A.i.5. The individual is capable of following rules, controlling behaviors, and seeking

assistance from staff or other professionals as needed within the structure of the

respite inpatient program.

RM.A.i.6. There is a substantial probability of initiation of acute inpatient treatment in the

absence of respite inpatient care.

RM.A.i.7. If the services being proposed have been attempted previously without significant



RM.A.i.8. The place of service meets the Service Setting Criteria for Respite Inpatient: Mental




RM.A.c.1. The individual continues to meet the treatment initiation criteria each day that


RM.A.c.2. There is an individualized habilitation or rehabilitation plan that specifies the goals,

interventions, time frames, and anticipated outcomes appropriate to improve or

prevent deterioration of the impairment in social functioning resulting from the

mental disorder or condition that necessitated initiation of treatment.

RM.A.c.3. The habilitation or rehabilitation goals, interventions, time frames, anticipated

outcomes, discharge plan, and criteria for discharge are clinically efficient,

reasonable, and achievable in the length of stay typically associated with care at this

level.

RM.A.c.4. Habilitation or rehabilitation services are being rendered in a timely and

appropriately progressive manner.

RM.A.c.5. There are daily progress notes by the treating psychiatrist and other appropriate staff


RM.A.c.6. As appropriate, members of the individual’s social support system are involved in



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SUPERVISED COMMUNITY RESIDENTIAL CARE/GROUP HOME

General Criteria


CR.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

CR.A.g.2. The services must be individualized, specific, and consistent with the individual’s


CR.A.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

CR.A.g.4. The individual complies with the essential elements of treatment.

CR.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

CR.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


CR.A.g.7. The services are not predominantly domiciliary or custodial.

CR.A.g.8. No exclusionary criteria of the health plan or benefit package are met.



CR.A.i.1. The individual has a primary diagnosis of a mental disorder according to the most

recent version of the Diagnostic and Statistical Manual of Mental Disorders that

requires, and is likely to respond to, professional therapeutic intervention.

CR.A.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



CR.A.i.3. As a result of the mental disorder, the individual’s social functioning has become

impaired to the extent that:

CR.A.i.3.1 The individual is, or is likely to become, a danger to self, a danger to

others, or unable to provide for basic self-care needs resulting in

serious self-harm.

OR

CR.A.i.3.2 The individual will require initiation of a higher level of care if

services are not provided at this level.


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CR.A.i.4. Supervised residential care combined with active behavioral health treatment can




disorder.

CR.A.i.5. The individual does not have adequate internal resources or an adequate external

support system to maintain functioning with outpatient services in the absence of the

structure of supervised community residential care.

CR.A.i.6. The individual is capable of following rules, controlling behaviors, and seeking


supervised residence.

CR.A.i.7. If the services being proposed have been attempted previously without significant



CR.A.i.8. The place of service meets the Service Setting Criteria for Supervised Community

Residential Care as described on page 27.



CR.A.c.1. The individual continues to meet the treatment initiation criteria each day that


CR.A.c.2. There is an individualized habilitation or rehabilitation plan that specifies the goals,



mental disorder that necessitated initiation of treatment.

CR.A.c.3. The habilitation or rehabilitation goals, interventions, time frames, anticipated


reasonable, and achievable in the length of stay typically associated with treatment

at this level.

CR.A.c.4. Habilitation or rehabilitation services are being rendered in a timely and


CR.A.c.5. There are periodic progress notes by appropriate professional and non-professional

staff describing the therapeutic interventions rendered and the individual’s response.

CR.A.c.6. As appropriate, members of the individual’s social support system are involved in

the individual’s treatment or appropriate efforts are made to enhance or develop the

individual’s social support system.


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PARTIAL HOSPITAL TREATMENT: MENTAL HEALTH

General Criteria


PM.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

PM.A.g.2. The services must be individualized, specific, and consistent with the individual’s


PM.A.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

PM.A.g.4. The individual complies with the essential elements of treatment.

PM.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

PM.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


PM.A.g.7. The services are not predominantly domiciliary or custodial.

PM.A.g.8. No exclusionary criteria of the health plan or benefit package are met.



PM.A.i.1. Based on a behavioral health history and mental status evaluation completed by a







intervention.

PM.A.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



PM.A.i.3. The individual does not have adequate internal resources or an adequate external

support system to maintain functioning without the support of an intensive multi-

modal, multi-disciplinary treatment program that includes medical and/or nursing

care.


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PM.A.i.4. With treatment at this level, the individual is capable of controlling behaviors and/or

seeking professional help when not in a structured treatment setting.

PM.A.i.5. If the services being proposed have been attempted previously without significant



PM.A.i.6. The place of service meets the Service Setting Criteria for Partial Hospital

Treatment: Mental Health as described on page 29.


PM.A.i.7. As a result of the mental disorder or condition, the individual is now a clear and

present danger to self, a clear and present danger to others, or unable to provide for

basic self-care needs resulting in impending, serious self-harm.

PM.A.i.8. As a result of the mental disorder or condition:

PM.A.i.8.1 The individual demonstrates significant impairment in social,

occupational, scholastic or role functioning that represents a

deterioration in level of functioning.

AND

PM.A.i.8.2 The individual has participated in and failed a substantial course of

traditional or intensive outpatient treatment in the past three months.

OR

PM.A.i.8.3 It is clinically probable that the individual will require initiation of a

higher level of care if services are not provided at this level.



PM.A.c.1. The individual continues to meet the treatment initiation criteria each day that


PM.A.c.2. There is an individualized plan of active, professionally directed treatment that


to:

PM.A.c.2.1 Improve or prevent deterioration or delay progression in a clinically




AND

PM.A.c.2.2 Address a co-morbid substance use disorder or condition, if one

exists.


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PM.A.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



PM.A.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

PM.A.c.5. Each day the individual receives services there are progress notes by appropriate

professional and non professional staff, and periodic notes by the treating

psychiatrist, describing the therapeutic interventions rendered and the individual’s

response.

PM.A.c.6. As appropriate, members of the individual’s social support system are involved in




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PARTIAL HOSPITAL TREATMENT: SUBSTANCE RELATED

General Criteria


PS.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

PS.A.g.2. The services must be individualized, specific, and consistent with the individual’s


PS.A.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

PS.A.g.4. The individual complies with the essential elements of treatment.

PS.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

PS.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


PS.A.g.7. The services are not predominantly domiciliary or custodial.

PS.A.g.8. No exclusionary criteria of the health plan or benefit package are met.



PS.A.i.1. Based on a behavioral health history and mental status evaluation completed by a








intervention.

PS.A.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



PS.A.i.3. The individual does not have adequate internal resources or an adequate external



care.


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PS.A.i.4. With treatment at this level, the individual is capable of controlling behaviors and/or


PS.A.i.5. If the services being proposed have been attempted previously without significant



PS.A.i.6. The place of service meets the Service Setting Criteria for Partial Hospital

Treatment: Substance Related as described on page 31.


PS.A.i.7. The individual is dependent on a class or classes and quantity or quantities of


Detoxification on page 167) and is capable of controlling behaviors and/or seeking

professional help when not in a structured treatment setting.

PS.A.i.8. The individual has participated in and failed a substantial course of traditional or

intensive outpatient treatment in the past three months.

PS.A.i.9. It is clinically probable that the individual will require treatment at a higher level of

care if services are not provided at this level.



PS.A.c.1. The individual continues to meet the treatment initiation criteria each day that


PS.A.c.2. There is an individualized plan of active, professionally directed treatment that


PS.A.c.2.1 Detoxify the individual from the substances requiring a medical

detoxification.

OR

PS.A.c.2.2 Improve or prevent deterioration or delay progression in a clinically



of treatment.

AND

PS.A.c.2.3 Address a co-morbid mental health disorder or condition, if one

exists.

PS.A.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



PS.A.c.4. Treatment is being rendered in a timely and appropriately progressive manner.


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PS.A.c.5. Each day the individual receives services there are progress notes by appropriate


psychiatrist or physician qualified in addiction medicine, describing the therapeutic


PS.A.c.6. As appropriate, members of the individual’s social support system are involved in




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INTENSIVE OUTPATIENT TREATMENT: MENTAL HEALTH

General Criteria


IM.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

IM.A.g.2. The services must be individualized, specific, and consistent with the individual’s


IM.A.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

IM.A.g.4. The individual complies with the essential elements of treatment.

IM.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

IM.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


IM.A.g.7. The services are not predominantly domiciliary or custodial.

IM.A.g.8. No exclusionary criteria of the health plan or benefit package are met.



IM.A.i.1. Based on a behavioral health history and mental status evaluation completed by a


independently prior to initiation of treatment, the individual is diagnosed as having,

or there is strong presumptive evidence that the individual has a diagnosis of, a

mental disorder or condition according to the most recent version of the Diagnostic

and Statistical Manual of Mental Disorders that requires, and is likely to respond to,


IM.A.i.2. The individual does not have adequate internal resources or an adequate external

support system to maintain functioning without the support of an intensive treatment

program.

IM.A.i.3. With treatment at this level, the individual is capable of controlling behaviors and/or


IM.A.i.4. If the services being proposed have been attempted previously without significant




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IM.A.i.5. The place of service meets the Service Setting Criteria for Intensive Outpatient:

Mental Health as described on page 33.


IM.A.i.6. As a result of the mental disorder or condition, the individual is a danger to self,

others or property but the risk can be adequately managed with multiple therapeutic

contacts per week.

IM.A.i.7. As a result of the mental disorder or condition, the individual demonstrates

significant impairment in social, occupational, scholastic or role functioning and it

is clinically probable that without multiple therapeutic contacts per week the

individual’s level of functioning would decline necessitating treatment at a higher

level of care.



IM.A.c.1. The individual continues to meet the treatment initiation criteria each day that


IM.A.c.2. There is an individualized plan of active, professionally directed treatment that


to:

IM.A.c.2.1 Improve or prevent deterioration or delay progression in a clinically




AND

IM.A.c.2.2 Address a co-morbid substance use disorder or condition, if one

exists.

IM.A.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



IM.A.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

IM.A.c.5. Each day the individual receives services there are progress notes by appropriate

professional and non-professional staff describing the therapeutic interventions

rendered and the individual’s response.

IM.A.c.6. As appropriate, members of the individual’s social support system are involved in




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INTENSIVE OUTPATIENT TREATMENT: SUBSTANCE RELATED

General Criteria


IS.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

IS.A.g.2. The services must be individualized, specific, and consistent with the individual’s


IS.A.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

IS.A.g.4. The individual complies with the essential elements of treatment.

IS.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

IS.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


IS.A.g.7. The services are not predominantly domiciliary or custodial.

IS.A.g.8. No exclusionary criteria of the health plan or benefit package are met.



IS.A.i.1. Based on a behavioral health and addictions history and mental status evaluation

completed by a behavioral health professional licensed, certified, or registered to

practice independently prior to initiation of treatment, the individual is diagnosed as

having, or there is strong presumptive evidence that the individual has a diagnosis

of, a substance related disorder or condition according to the most recent version of

the Diagnostic and Statistical Manual of Mental Disorders that requires, and is

likely to respond to, professional therapeutic intervention.

IS.A.i.2. The individual does not have adequate internal resources or an adequate external

support system to maintain functioning without the support of an intensive treatment

program.

IS.A.i.3. With treatment at this level, the individual is capable of controlling behaviors and/or


IS.A.i.4. If the services being proposed have been attempted previously without significant




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IS.A.i.5. The place of service meets the Service Setting Criteria for Intensive Outpatient:



IS.A.i.6. The individual is dependent on a class or classes and quantity or quantities of


Detoxification on page 167) and the individual is capable of controlling behaviors

and/or seeking professional help when not in a structured treatment setting.

IS.A.i.7. The individual has participated in and failed a substantial course of traditional

outpatient treatment in the past three months.

IS.A.i.8. It is clinically probable that without multiple therapeutic contacts per week the

individual will require treatment at a higher level of care.



IS.A.c.1. The individual continues to meet the treatment initiation criteria each day that


IS.A.c.2. There is an individualized plan of active, professionally directed treatment that


IS.A.c.2.1 Detoxify the individual from the substances requiring a medical

detoxification.

OR

IS.A.c.2.2 Improve or prevent deterioration or delay progression in a clinically


resulting from, the substance use disorder or condition that


AND

IS.A.c.2.3 Address a co-morbid mental health disorder or condition, if one

exists.

IS.A.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



IS.A.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

IS.A.c.5. Each day the individual receives services there are progress notes by appropriate



IS.A.c.6. As appropriate, members of the individual’s social support system are involved in




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General Criteria


CI.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

CI.A.g.2. The services must be individualized, specific, and consistent with the individual’s


CI.A.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

CI.A.g.4. The individual complies with the essential elements of treatment.

CI.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

CI.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


CI.A.g.7. The services are not predominantly domiciliary or custodial.

CI.A.g.8. No exclusionary criteria of the health plan or benefit package are met.



CI.A.i.1. Based on a behavioral health history and mental status evaluation completed by a


independently prior to, or at the time of, initiation of treatment the individual is

diagnosed as having, or there is strong presumptive evidence that the individual has

a diagnosis of, a mental disorder or condition according to the most recent version

of the Diagnostic and Statistical Manual of Mental Disorders that requires, and is


CI.A.i.2. As a result of the mental disorder or condition, the individual has recently developed

symptoms that put the individual at significant risk for treatment at a higher level of

care because the individual is, or is likely to become, a danger to self, a danger to

others, or significantly impaired in ability to provide for basic self-care needs.

CI.A.i.3. It is clinically probable that the individual’s symptoms can be improved or

stabilized, and treatment at a higher level of care avoided, with multiple therapeutic

contacts in a short period of time.


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CI.A.i.4. The individual does not have adequate internal resources or an adequate external

support system to maintain functioning without the addition of intensive treatment.

CI.A.i.5. With treatment at this level, the individual is capable of controlling behaviors and/or

seeking professional help.

CI.A.i.6. If the services being proposed have been attempted previously without significant



CI.A.i.7. The place of service meets the Service Setting Criteria for Outpatient Crisis

Intervention as described on page 37.



CI.A.c.1. The individual continues to meet the treatment initiation criteria each day that


CI.A.c.2. There is an individualized plan of active, professionally directed treatment that

focuses on interventions to rapidly improve or prevent deterioration of the

symptoms of, or impairment in functioning resulting from, the mental disorder that


CI.A.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



CI.A.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

CI.A.c.5. It remains clinically probable that treatment at a higher level of care can be avoided.

CI.A.c.6. There is a progress note by the treating practitioner for each treatment session


CI.A.c.7. As appropriate, members of the individual’s social support system are involved in

the crisis intervention treatment.


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MOBILE TEAM

General Criteria


MT.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

MT.A.g.2. The services must be individualized, specific, and consistent with the individual’s


MT.A.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

MT.A.g.4. The individual complies with the essential elements of treatment.

MT.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

MT.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


MT.A.g.7. The services are not predominantly domiciliary or custodial.

MT.A.g.8. No exclusionary criteria of the health plan or benefit package are met.



MT.A.i.1. Based on a behavioral health history and mental status evaluation completed by a


independently prior to, or at the time of, the mobile team’s visit the individual is





MT.A.i.2. As a result of the mental disorder or condition, the individual is at imminent risk for

treatment at a higher level of care because the individual is a danger to self, a danger

to others, or demonstrates a rapid deterioration in ability to provide for basic self-

care needs.

MT.A.i.3. The individual cannot, or will not agree to, be transported to a formal treatment

setting but the individual, or the individual’s surrogate decision-maker, agrees to at-

home evaluation and/or treatment by the mobile team.


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MT.A.i.4. It is clinically probable that treatment at a higher level of care can be avoided with

mobile team services.

MT.A.i.5. The individual does not have adequate internal resources or an adequate external

support system to maintain functioning without the support of mobile team

treatment.

MT.A.i.6. With treatment at this level, the individual’s danger to self, danger to others or

deterioration in ability to provide for basic self-care needs can be adequately

managed.

MT.A.i.7. If the services being proposed have been attempted previously without significant



MT.A.i.8. The service being provided meets the Service Setting Criteria for Mobile Team as

described on page 39.



MT.A.c.1. The individual continues to meet the treatment initiation criteria each day that


MT.A.c.2. There is an individualized plan of active, professionally directed treatment that


symptoms of, or impairment in functioning resulting from, the mental disorder or

condition that necessitated initiation of treatment.

MT.A.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



MT.A.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

MT.A.c.5. It remains clinically probable that treatment at a higher level of care can be avoided.

MT.A.c.6. There is a progress note by the treating practitioner for each treatment session


MT.A.c.7. As appropriate, members of the individual’s social support system are involved in



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General Criteria


HH.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

HH.A.g.2. The services must be individualized, specific, and consistent with the individual’s


HH.A.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

HH.A.g.4. The individual complies with the essential elements of treatment.

HH.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

HH.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


HH.A.g.7. The services are not predominantly domiciliary or custodial.

HH.A.g.8. No exclusionary criteria of the health plan or benefit package are met.



HH.A.i.1. Based on a behavioral health history and mental status evaluation completed by a


independently prior to the home health visit, the individual is diagnosed as having,





HH.A.i.2. As a result of the mental disorder or condition, the individual is now, or is likely to

become, a danger to self, a danger to others, or significantly impaired in social,


HH.A.i.3. Either:

HH.A.i.3.1 The individual is unable to leave home for treatment but the

individual, or the individual’s surrogate decision-maker, agrees to

home health services.

OR


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HH.A.i.3.2 The individual is able but unwilling to leave home for treatment and

the individual, or the individual’s surrogate decision-maker, agrees to

home health services; and it is clinically probable that treatment at a

higher level of care can be avoided with home health services.

OR

HH.A.i.3.3 Evaluation and treatment in the home setting is likely to increase the

effectiveness and efficiency of the clinical intervention.

HH.A.i.4. The individual does not have adequate internal resources or an adequate external

support system to maintain functioning without home health services.

HH.A.i.5. The individual’s actual or potential danger to self, danger to others or deterioration

in ability to provide for basic self-care needs can be improved or stabilized by

therapeutic intervention at this level.

HH.A.i.6. If the services being proposed have been attempted previously without significant



HH.A.i.7. The service being provided meets the Service Setting Criteria for Home Health

Services as described on page 40.



HH.A.c.1. The individual continues to meet the treatment initiation criteria each day that


HH.A.c.2. There is an individualized plan of active, professionally directed treatment that


to improve or prevent deterioration or delay progression in a clinically meaningful

way of the symptoms of, or impairment in functioning resulting from, the mental

disorder or condition that necessitated initiation of treatment.

HH.A.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



HH.A.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

HH.A.c.5. There is a progress note by the treating practitioner for each home health visit


HH.A.c.6. As appropriate, members of the individual’s social support system are involved in



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TRADITIONAL OUTPATIENT TREATMENT: MENTAL HEALTH

General Criteria


OM.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

OM.A.g.2. The services must be individualized, specific, and consistent with the individual’s


OM.A.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

OM.A.g.4. The individual complies with the essential elements of treatment.

OM.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

OM.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


OM.A.g.7. The services are not predominantly domiciliary or custodial.

OM.A.g.8. No exclusionary criteria of the health plan or benefit package are met.



OM.A.i.1. Based on a behavioral health history and mental status evaluation completed by a







OM.A.i.2. As a result of the mental disorder or condition:

OM.A.i.2.1 The individual is experiencing significant distress or impairment in

social, occupational, scholastic or role functioning. (Transient,

expected reactions to psychosocial stressors are not sufficient to meet

this criterion.)

OR

OM.A.i.2.2 The individual has a persistent disorder according to the most recent

version of the Diagnostic and Statistical Manual of Mental Disorders


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for which maintenance treatment is required to maintain relief of

symptoms or level of functioning.

OM.A.i.3. The individual has adequate internal resources or an adequate external support

system to maintain functioning without the support of a more intensive treatment

program.

OM.A.i.4. With treatment at this level, the individual is capable of controlling behaviors and/or

seeking professional help when not in a treatment setting.

OM.A.i.5. If the services being proposed have been attempted previously without significant



OM.A.i.6. The place of service meets the Service Setting Criteria for Traditional Outpatient:




OM.A.c.1. The individual continues to meet the treatment initiation criteria each day that


OM.A.c.2. Either:

OM.A.c.2.1 The individual’s GAF is <70.

OR

OM.A.c.2.2 The individual has a persistent disorder according to the most recent




OM.A.c.3. There is an individualized plan of active, professionally directed treatment that





OM.A.c.4. The treatment goals, interventions, time frames, anticipated outcomes, discharge



OM.A.c.5. Treatment is being rendered in a timely and appropriately progressive manner.

OM.A.c.6. There is a progress note by the treating practitioner for each treatment session


OM.A.c.7. As appropriate, members of the individual’s social support system are involved in




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TRADITIONAL OUTPATIENT TREATMENT: SUBSTANCE RELATED

General Criteria


OS.A.g.1. The services must be consistent with nationally accepted standards of medical

practice.

OS.A.g.2. The services must be individualized, specific, and consistent with the individual’s


OS.A.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

OS.A.g.4. The individual complies with the essential elements of treatment.

OS.A.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

OS.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


OS.A.g.7. The services are not predominantly domiciliary or custodial.

OS.A.g.1. No exclusionary criteria of the health plan or benefit package are met.



OS.A.i.1. Based on a behavioral health history and mental status evaluation completed by a




substance related disorder or condition according to the most recent version of the

Diagnostic and Statistical Manual of Mental Disorders that requires, and is likely to

respond to, professional therapeutic intervention.

OS.A.i.2. As a result of the substance related disorder or condition:

OS.A.i.2.1 The individual is experiencing significant distress or impairment in



this criterion.)

OR

OS.A.i.2.2 The individual has a persistent disorder according to the most recent



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OS.A.i.3. The individual has adequate internal resources or an adequate external support


program.

OS.A.i.4. With treatment at this level, the individual is capable of controlling behaviors and/or

seeking professional help when not in a treatment setting.

OS.A.i.5. If the services being proposed have been attempted previously without significant



OS.A.i.6. The place of service meets the Service Setting Criteria for Traditional Outpatient:




OS.A.c.1. The individual continues to meet the treatment initiation criteria each day that


OS.A.c.2. Either:

OS.A.c.2.1 The individual’s GAF is <70.

OR

OS.A.c.2.2 The individual has a persistent disorder according to the most recent




OS.A.c.3. There is an individualized plan of active, professionally directed treatment that



way of the symptoms of, or impairment in functioning resulting from, the substance

use disorder or condition that necessitated initiation of treatment.

OS.A.c.4. The treatment goals, interventions, time frames, anticipated outcomes, discharge



OS.A.c.5. Treatment is being rendered in a timely and appropriately progressive manner.

OS.A.c.6. There is a progress note by the treating practitioner for each treatment session


OS.A.c.7. As appropriate, members of the individual’s social support system are involved in




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CHILD AND ADOLESCENT



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Child and Adolescent Level of Care Criteria



General Criteria


AM.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

AM.C.g.2. The services must be individualized, specific, and consistent with the individual’s


AM.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

AM.C.g.4. The individual complies with the essential elements of treatment.

AM.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

AM.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


AM.C.g.7. The services are not predominantly domiciliary or custodial.

AM.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



AM.C.i.1. Based on a behavioral health history and mental status evaluation completed by a







intervention.

AM.C.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



AM.C.i.3. As a result of the mental disorder or condition:

AM.C.i.3.1 The individual’s level of functioning has deteriorated such that the



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OR

AM.C.i.3.2 The individual requires an unusual or medically dangerous form of



AM.C.i.4. Continuous skilled behavioral health nursing care, not just twenty-four hour per day



AM.C.i.4.1 The individual is likely to require restraints or seclusion.

OR

AM.C.i.4.2 There is a significant probability that the individual will experience


medications.

OR

AM.C.i.4.3 The individual is, or there is a significant probability that the



AM.C.i.5. If the services being proposed have been attempted previously without significant



AM.C.i.6. The place of service meets the Service Setting Criteria for Acute Inpatient: Mental




AM.C.c.1. The individual continues to meet the treatment initiation criteria each day that


AM.C.c.2. There is an individualized plan of active, professionally directed treatment that


to:

AM.C.c.2.1 Improve or prevent deterioration or delay progression in a clinically




AND


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AM.C.c.2.2 Address a co-morbid substance use disorder or condition, if one

exists.

AM.C.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



AM.C.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

AM.C.c.5. There are daily progress notes by the treating psychiatrist and other appropriate staff


AM.C.c.6. As appropriate, parents, guardians, and/or other members of the individual’s social

support system are involved in the individual’s treatment.


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General Criteria


AS.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

AS.C.g.2. The services must be individualized, specific, and consistent with the individual’s


AS.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

AS.C.g.4. The individual complies with the essential elements of treatment.

AS.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

AS.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


AS.C.g.7. The services are not predominantly domiciliary or custodial.

AS.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



AS.C.i.1. Based on a behavioral health history and mental status evaluation completed by a

psychiatrist, physician qualified in addiction medicine or by a behavioral health







intervention.

AS.C.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



AS.C.i.3. The individual is dependent on a class or classes and quantity or quantities of




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AS.C.i.4. Continuous skilled behavioral health nursing care, not just twenty-four hour per day



AS.C.i.4.1 The individual has a history of medically complicated detoxification

episodes.

OR

AS.C.i.4.2 The individual has unstable vital signs not treatable on an outpatient

basis.

OR

AS.C.i.4.3 The individual has a medical co-morbidity that significantly increases



AS.C.i.5. The place of service meets the Service Setting Criteria for Acute Inpatient:




AS.C.c.1. The individual continues to meet the treatment initiation criteria each day that


AS.C.c.2. There is an individualized plan of active, professionally directed treatment that


AS.C.c.2.1 Detoxify the individual from the substances requiring a medical

detoxification.

AND

AS.C.c.2.2 Address a co-morbid mental health disorder or condition, if one

exists.

AS.C.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



AS.C.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

AS.C.c.5. There are daily progress notes by the treating psychiatrist or physician qualified in



AS.C.c.6. As appropriate, parents, guardians, and/or other members of the individual’s social



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General Criteria


OB.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

OB.C.g.2. The services must be individualized, specific, and consistent with the individual’s


OB.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

OB.C.g.4. The individual complies with the essential elements of treatment.

OB.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

OB.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


OB.C.g.7. The services are not predominantly domiciliary or custodial.

OB.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



OB.C.i.1. Based on a behavioral health history and mental status evaluation completed by a









OB.C.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



OB.C.i.3. As a result of the mental or substance related disorder or condition:

OB.C.i.3.1 The individual’s level of functioning has deteriorated such that the



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OR

OB.C.i.3.2 The individual is dependent on a class or classes and quantity or



OB.C.i.4. Continuous skilled behavioral health nursing care, not just twenty-four hour per day



OB.C.i.4.1 The individual is likely to require restraints or seclusion.

OR

OB.C.i.4.2 The individual has experienced, or there is a significant likelihood



OR

OB.C.i.4.3 The individual has a history of medically complicated detoxification

episodes.

OR

OB.C.i.4.4 The individual has unstable vital signs not treatable on an outpatient



OR

OB.C.i.4.5 The individual has a medical co-morbidity that significantly increases



OB.C.i.5. The individual’s presentation may stabilize, improve, or resolve making treatment at

a lower level of care possible within 23 hours.

OB.C.i.6. The place of service meets the Service Setting Criteria for 23-hour Inpatient





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General Criteria


SM.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

SM.C.g.2. The services must be individualized, specific, and consistent with the individual’s


SM.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

SM.C.g.4. The individual complies with the essential elements of treatment.

SM.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

SM.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


SM.C.g.7. The services are not predominantly domiciliary or custodial.

SM.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



SM.C.i.1. Based on a behavioral health history and mental status evaluation completed by a







intervention.

SM.C.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



SM.C.i.3. As a result of the mental disorder or condition, the individual’s level of functioning





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SM.C.i.4. The individual is not capable of controlling behaviors, providing for his/her own

basic self-care needs or seeking professional help with the structure and support

available from a family and community support system and therefore requires

treatment in a structured setting providing twenty-four hour per day supervision by

trained personnel.

SM.C.i.5. There is a substantial probability of initiation of acute inpatient treatment in the


SM.C.i.6. If the services being proposed have been attempted previously without significant



SM.C.i.7. The place of service meets the Service Setting Criteria for Sub-Acute Inpatient




SM.C.c.1. The individual continues to meet the treatment initiation criteria each day that


SM.C.c.2. There is an individualized plan of active, professionally directed treatment that


to:

SM.C.c.2.1 Improve or prevent deterioration or delay progression in a clinically




AND

SM.C.c.2.2 Address a co-morbid substance use disorder or condition, if one

exists.

SM.C.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



SM.C.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

SM.C.c.5. There are daily progress notes by the treating psychiatrist and other appropriate staff


SM.C.c.6. As appropriate, parents, guardians, and/or other members of the individual’s social



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General Criteria


SS.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

SS.C.g.2. The services must be individualized, specific, and consistent with the individual’s


SS.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

SS.C.g.4. The individual complies with the essential elements of treatment.

SS.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

SS.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


SS.C.g.7. The services are not predominantly domiciliary or custodial.

SS.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



SS.C.i.1. Based on a behavioral health history and mental status evaluation completed by a








intervention.

SS.C.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



SS.C.i.3. If the services being proposed have been attempted previously without significant




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SS.C.i.4. The place of service meets the Service Setting Criteria for Sub-Acute Inpatient



SS.C.i.5. The individual is dependent on a class or classes and quantity or quantities of


Detoxification on page 167) and the individual’s home environment does not

provide the supervision, support, or access to therapeutic services necessary for

outpatient detoxification.

SS.C.i.6. The individual is seriously medically compromised and risks significant acute


controlling substance use with the structure and support available from a family and

community support system and therefore requires twenty-four hour per day staff

supervision.

SS.C.i.7. There is significant impairment in the individual’s social, occupational, scholastic or

role functioning as a result of the substance dependence and there is a clinically

credible rationale for why treatment in a structured setting with twenty-four hour per

day staff supervision will substantially reverse the impairment in social,




SS.C.c.1. The individual continues to meet the treatment initiation criteria each day that


SS.C.c.2. There is an individualized plan of active, professionally directed treatment that


SS.C.c.2.1 Detoxify the individual from the substances requiring a medical

detoxification.

OR

SS.C.c.2.2 Improve or prevent deterioration or delay progression in a clinically



of treatment.

AND

SS.C.c.2.3 Address a co-morbid mental health disorder or condition, if one

exists.

SS.C.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge




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SS.C.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

SS.C.c.5. There are daily progress notes by the treating psychiatrist or physician qualified in



SS.C.c.6. As appropriate, parents, guardians, and/or other members of the individual’s social



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General Criteria


CR.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

CR.C.g.2. The services must be individualized, specific, and consistent with the individual’s


CR.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

CR.C.g.4. The individual complies with the essential elements of treatment.

CR.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

CR.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


CR.C.g.7. The services are not predominantly domiciliary or custodial.

CR.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



CR.C.i.1. The individual has a primary diagnosis of a mental disorder according to the most



CR.C.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



CR.C.i.3. As a result of the mental disorder, the individual’s social functioning has become


CR.C.i.3.1 The individual is, or is likely to become, a danger to self, a danger to


serious self-harm.

OR

CR.C.i.3.2 The individual will require initiation of a higher level of care if



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CR.C.i.4. Supervised residential care combined with active behavioral health treatment can




disorder.

CR.C.i.5. The individual does not have adequate internal resources to maintain functioning

with outpatient services and the structure and support found in a home or

therapeutic foster care setting.

CR.C.i.6. The individual is capable of following rules, controlling behaviors, and seeking

assistance from staff or other professionals as needed within the structure of a


CR.C.i.7. If the services being proposed have been attempted previously without significant



CR.C.i.8. The place of service meets the Service Setting Criteria for Supervised Community




CR.C.c.1. The individual continues to meet the treatment initiation criteria each day that


CR.C.c.2. There is an individualized habilitation or rehabilitation plan that specifies the goals,


prevent deterioration or delay progression in a clinically meaningful way of the

impairment in functioning resulting from the mental disorder that necessitated


CR.C.c.3. The habilitation or rehabilitation goals, interventions, time frames, anticipated



at this level.

CR.C.c.4. Habilitation or rehabilitation services are being rendered in a timely and


CR.C.c.5. There are periodic progress notes by appropriate professional and non-professional


CR.C.c.6. As appropriate, parents, guardians, and/or other members of the individual’s social

support system are involved in the individual’s treatment or appropriate efforts are

made to enhance or develop the individual’s social support system.


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THERAPEUTIC FOSTER CARE

General Criteria


TF.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

TF.C.g.2. The services must be individualized, specific, and consistent with the individual’s


TF.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

TF.C.g.4. The individual complies with the essential elements of treatment.

TF.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

TF.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


TF.C.g.7. The services are not predominantly domiciliary or custodial.

TF.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



TF.C.i.1. The individual has a primary diagnosis of a mental disorder according to the most



TF.C.i.2. As a result of the mental disorder, there is a significant impairment in the

individual’s social, occupational, scholastic or role functioning that puts the

individual or others at risk.

TF.C.i.3. The individual’s internal resources, home environment, family resources, and

support network are inadequate to provide the structure and support needed by the

individual.

TF.C.i.4. The individual is capable of following rules, controlling behaviors, and seeking

assistance from a foster family sufficient to be maintained in a family setting with

the added support of a therapeutic foster care program.

TF.C.i.5. Therapeutic foster care combined with active behavioral health treatment can

stabilize or improve the individual’s functioning permitting the individual to live


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safely in the community, provide for basic self-care needs, participate in behavioral

health treatment, and cope with the sequelae of his/her behavioral health disorder.

TF.C.i.6. If the services being proposed have been attempted previously without significant



TF.C.i.7. The place of service meets the Service Setting Criteria for Therapeutic Foster Care

as described on page 23.



TF.C.c.1. The individual continues to meet the treatment initiation criteria each day that


TF.C.c.2. The individual is receiving clinical benefit from the therapeutic foster care as

evidenced by stabilization of or improvement in one or more of the functional areas

that necessitated therapeutic placement.

TF.C.c.3. As appropriate, parents, guardians, and/or other members of the individual’s social




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General Criteria


PM.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

PM.C.g.2. The services must be individualized, specific, and consistent with the individual’s


PM.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

PM.C.g.4. The individual complies with the essential elements of treatment.

PM.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

PM.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


PM.C.g.7. The services are not predominantly domiciliary or custodial.

PM.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



PM.C.i.1. Based on a behavioral health history and mental status evaluation completed by a







intervention.

PM.C.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



PM.C.i.3. The individual’s internal resources, home environment, family resources, and


individual without the addition of an intensive multi-modal, multi-disciplinary

treatment program that includes medical and/or nursing care.


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PM.C.i.4. With treatment at this level, the individual is capable of following rules, controlling

behaviors, and seeking assistance from appropriate members of the individual’s

social support system when not in a structured treatment setting.

PM.C.i.5. If the services being proposed have been attempted previously without significant



PM.C.i.6. The place of service meets the Service Setting Criteria for Partial Hospital



PM.C.i.7. As a result of the mental disorder or condition, the individual is now a clear and



PM.C.i.8. As a result of the mental disorder or condition:

PM.C.i.8.1 The individual demonstrates significant impairment in social,

occupational, scholastic or role functioning that represents a

deterioration in level of functioning.

AND

PM.C.i.8.2 The individual has participated in and failed a substantial course of


OR

PM.C.i.8.3 It is clinically probable that the individual will require treatment at a




PM.C.c.1. The individual continues to meet the treatment initiation criteria each day that


PM.C.c.2. There is an individualized plan of active, professionally directed treatment that


to:

PM.C.c.2.1 Improve or prevent deterioration or delay progression in a clinically




AND

PM.C.c.2.2 Address a co-morbid substance use disorder or condition, if one

exists.


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PM.C.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



PM.C.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

PM.C.c.5. Each day the individual receives services there are progress notes by appropriate



response.

PM.C.c.6. As appropriate, parents, guardians, and/or other members of the individual’s social




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General Criteria


PS.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

PS.C.g.2. The services must be individualized, specific, and consistent with the individual’s


PS.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

PS.C.g.4. The individual complies with the essential elements of treatment.

PS.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

PS.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


PS.C.g.7. The services are not predominantly domiciliary or custodial.

PS.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



PS.C.i.1. Based on a behavioral health history and mental status evaluation completed by a








intervention.

PS.C.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



PS.C.i.3. The individual’s internal resources, home environment, family resources, and


individual without the addition of an intensive multi-modal, multi-disciplinary

treatment program that includes medical and/or nursing care.


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PS.C.i.4. With treatment at this level, the individual is capable of following rules, controlling



PS.C.i.5. If the services being proposed have been attempted previously without significant



PS.C.i.6. The place of service meets the Service Setting Criteria for Partial Hospital



PS.C.i.7. The individual is dependent on a class or classes and quantity or quantities of




PS.C.i.8. The individual has participated in and failed a substantial course of traditional or


PS.C.i.9. It is clinically probable that the individual will require treatment at a higher level of




PS.C.c.1. The individual continues to meet the treatment initiation criteria each day that


PS.C.c.2. There is an individualized plan of active, professionally directed treatment that


PS.C.c.2.1 Detoxify the individual from the substances requiring a medical

detoxification.

OR

PS.C.c.2.2 Improve or prevent deterioration or delay progression in a clinically



of treatment.

AND

PS.C.c.2.3 Address a co-morbid mental health disorder or condition, if one

exists.

PS.C.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



PS.C.c.4. Treatment is being rendered in a timely and appropriately progressive manner.


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PS.C.c.5. Each day the individual receives services there are progress notes by appropriate




PS.C.c.6. As appropriate, parents, guardians, and/or other members of the individual’s social




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General Criteria


IM.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

IM.C.g.2. The services must be individualized, specific, and consistent with the individual’s


IM.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

IM.C.g.4. The individual complies with the essential elements of treatment.

IM.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

IM.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


IM.C.g.7. The services are not predominantly domiciliary or custodial.

IM.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



IM.C.i.1. Based on a behavioral health history and mental status evaluation completed by a







IM.C.i.2. The individual’s internal resources, home environment, family resources, and


individual without the addition of an intensive treatment program.

IM.C.i.3. With treatment at this level, the individual is capable of following rules, controlling




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IM.C.i.4. If the services being proposed have been attempted previously without significant



IM.C.i.5. The place of service meets the Service Setting Criteria for Intensive Outpatient:



IM.C.i.6. As a result of the mental disorder or condition, the individual is a danger to self,


contacts per week.

IM.C.i.7. As a result of the mental disorder or condition, the individual demonstrates

significant impairment in social, occupational, scholastic or role functioning and it

is clinically probable that without multiple therapeutic contacts per week the


level of care.



IM.C.c.1. The individual continues to meet the treatment initiation criteria each day that


IM.C.c.2. There is an individualized plan of active, professionally directed treatment that


to:

IM.C.c.2.1 Improve or prevent deterioration or delay progression in a clinically




AND

IM.C.c.2.2 Address a co-morbid substance use disorder or condition, if one

exists.

IM.C.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



IM.C.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

IM.C.c.5. Each day the individual receives services there are progress notes by appropriate




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IM.C.c.6. As appropriate, parents, guardians, and/or other members of the individual’s social




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General Criteria


IS.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

IS.C.g.2. The services must be individualized, specific, and consistent with the individual’s


IS.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

IS.C.g.4. The individual complies with the essential elements of treatment.

IS.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

IS.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


IS.C.g.7. The services are not predominantly domiciliary or custodial.

IS.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



IS.C.i.1. Based on a behavioral health history and mental status evaluation completed by a







IS.C.i.2. The individual’s internal resources, home environment, family resources, and



IS.C.i.3. With treatment at this level, the individual is capable of following rules, controlling




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IS.C.i.4. If the services being proposed have been attempted previously without significant



IS.C.i.5. The place of service meets the Service Setting Criteria for Intensive Outpatient:



IS.C.i.6. The individual is dependent on a class or classes and quantity or quantities of




IS.C.i.7. The individual has participated in and failed a substantial course of traditional


IS.C.i.8. It is clinically probable that without multiple therapeutic contacts per week the


level of care.



IS.C.c.1. The individual continues to meet the treatment initiation criteria each day that


IS.C.c.2. There is an individualized plan of active, professionally directed treatment that


IS.C.c.2.1 Detoxify the individual from the substances requiring a medical

detoxification

OR

IS.C.c.2.2 Improve or prevent deterioration or delay progression in a clinically




AND

IS.C.c.2.3 Address a co-morbid mental health disorder or condition, if one

exists.

IS.C.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



IS.C.c.4. Treatment is being rendered in a timely and appropriately progressive manner.


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IS.C.c.5. Each day the individual receives services there are daily progress notes by

appropriate professional and non-professional staff describing the therapeutic


IS.C.c.6. As appropriate, parents, guardians, and/or other members of the individual’s social




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General Criteria


CI.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

CI.C.g.2. The services must be individualized, specific, and consistent with the individual’s


CI.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

CI.C.g.4. The individual complies with the essential elements of treatment.

CI.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

CI.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


CI.C.g.7. The services are not predominantly domiciliary or custodial.

CI.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



CI.C.i.1. Based on a behavioral health history and mental status evaluation completed by a


independently prior to, or at the time of initiation of treatment, the individual is





CI.C.i.2. As a result of the mental disorder or condition, the individual has recently developed




CI.C.i.3. It is clinically probable that the individual’s symptoms can be improved or




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CI.C.i.4. The individual’s internal resources, home environment, family resources, and


individual without the addition of intensive treatment.

CI.C.i.5. With treatment at this level, the individual is capable of following rules, controlling


social support system.

CI.C.i.6. If the services being proposed have been attempted previously without significant



CI.C.i.7. The place of service meets the Service Setting Criteria for Outpatient Crisis




CI.C.c.1. The individual continues to meet the treatment initiation criteria each day that


CI.C.c.2. There is an individualized plan of active, professionally directed treatment that




CI.C.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



CI.C.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

CI.C.c.5. It remains clinically probable that acute treatment at a higher level of care can be

avoided.

CI.C.c.6. There is a progress note by the treating practitioner for each treatment session


CI.C.c.7. As appropriate, parents, guardians, and/or other members of the individual’s social

support system are involved in the crisis intervention treatment.


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MOBILE TEAM

General Criteria


MT.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

MT.C.g.2. The services must be individualized, specific, and consistent with the individual’s


MT.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

MT.C.g.4. The individual complies with the essential elements of treatment.

MT.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

MT.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


MT.C.g.7. The services are not predominantly domiciliary or custodial.

MT.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



MT.C.i.1. Based on a behavioral health history and mental status evaluation completed by a


independently prior to, or at the time of the mobile team’s visit, the individual is





MT.C.i.2. As a result of the mental disorder, the individual is at imminent risk for treatment at

a higher level of care because the individual is a danger to self, a danger to others,

or demonstrates a rapid deterioration in ability to provide for basic self-care needs.

MT.C.i.3. The individual cannot, or will not agree to, be transported to a formal treatment

setting but the individual, or the individual’s parent or guardian, agrees to at-home

evaluation and/or treatment by the mobile team.

MT.C.i.4. It is clinically probable that treatment at a higher level of care can be avoided with



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MT.C.i.5. The individual’s internal resources, home environment, family resources, and


individual without mobile team treatment.

MT.C.i.6. With treatment at this level, the individual’s danger to self, danger to others or


managed.

MT.C.i.7. If the services being proposed have been attempted previously without significant



MT.C.i.8. The service being provided meets the Service Setting Criteria for Mobile Team as




MT.C.c.1. The individual continues to meet the treatment initiation criteria each day that


MT.C.c.2. There is an individualized plan of active, professionally directed treatment that




MT.C.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



MT.C.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

MT.C.c.5. It remains clinically probable that treatment at a higher level of care can be avoided.

MT.C.c.6. There is a progress note by the treating practitioner for each treatment session


MT.C.c.7. As appropriate, parents, guardians, and/or other members of the individual’s social



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General Criteria


HH.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

HH.C.g.2. The services must be individualized, specific, and consistent with the individual’s


HH.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

HH.C.g.4. The individual complies with the essential elements of treatment.

HH.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

HH.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


HH.C.g.7. The services are not predominantly domiciliary or custodial.

HH.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



HH.C.i.1. Based on a behavioral health history and mental status evaluation completed by a




mental disorder according or condition to the most recent version of the Diagnostic



HH.C.i.2. As a result of the mental disorder or condition, the individual is now, or is likely to



HH.C.i.3. Either:

HH.C.i.3.1 The individual is unable to leave home for treatment and the

individual, or the individual’s parent or guardian, agrees to home

health services.

OR


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HH.C.i.3.2 The individual is able but unwilling to leave home for treatment; and

the individual, or the individual’s parent or guardian, agrees to home

health services; and it is clinically probable that treatment at a higher

level of care can be avoided with home health services.

OR

HH.C.i.3.3 Evaluation and treatment in the home setting is likely to increase the


HH.C.i.4. The individual’s internal resources, home environment, family resources, and


individual without the addition of home health services.

HH.C.i.5. The individual’s actual or potential danger to self, danger to others or deterioration



HH.C.i.6. If the services being proposed have been attempted previously without significant



HH.C.i.7. The service being provided meets the Service Setting Criteria for Home Health




HH.C.c.1. The individual continues to meet the treatment initiation criteria each day that


HH.C.c.2. There is an individualized plan of active, professionally directed treatment that





HH.C.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



HH.C.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

HH.C.c.5. There is a progress note by the treating practitioner for each home health visit


HH.C.c.6. As appropriate, parents, guardians, and/or other members of the individual’s social



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General Criteria


OM.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

OM.C.g.2. The services must be individualized, specific, and consistent with the individual’s


OM.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

OM.C.g.4. The individual complies with the essential elements of treatment.

OM.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

OM.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


OM.C.g.7. The services are not predominantly domiciliary or custodial.

OM.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



OM.C.i.1. Based on a behavioral health history and mental status evaluation completed by a







OM.C.i.2. As a result of the mental disorder or condition:

OM.C.i.2.1 The individual is experiencing significant distress or impairment in



this criterion.)

OR

OM.C.i.2.2 The individual has a persistent disorder according to the most recent



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OM.C.i.3. The individual’s internal resources, home environment, family resources, and

support network are adequate to provide the structure and support needed by the

individual.

OM.C.i.4. With treatment at this level, the individual is capable of following rules, controlling


social support system when not in a treatment setting.

OM.C.i.5. If the services being proposed have been attempted previously without significant



OM.C.i.6. The place of service meets the Service Setting Criteria for Traditional Outpatient:




OM.C.c.1. The individual continues to meet the treatment initiation criteria each day that


OM.C.c.2. Either:

OM.C.c.2.1 The individual’s GAF is <70.

OR

OM.C.c.2.2 The individual has a persistent disorder according to the most recent




OM.C.c.3. There is an individualized plan of active, professionally directed treatment that





OM.C.c.4. The treatment goals, interventions, time frames, anticipated outcomes, discharge



OM.C.c.5. Treatment is being rendered in a timely and appropriately progressive manner.

OM.C.c.6. There is a progress note by the treating practitioner for each treatment session



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OM.C.c.7. As appropriate, parents, guardians, and/or other members of the individual’s social




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General Criteria


OS.C.g.1. The services must be consistent with nationally accepted standards of medical

practice.

OS.C.g.2. The services must be individualized, specific, and consistent with the individual’s


OS.C.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

OS.C.g.4. The individual complies with the essential elements of treatment.

OS.C.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

OS.C.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


OS.C.g.7. The services are not predominantly domiciliary or custodial.

OS.C.g.8. No exclusionary criteria of the health plan or benefit package are met.



OS.C.i.1. Based on a behavioral health history and mental status evaluation completed by a







OS.C.i.2. As a result of the substance related disorder or condition:

OS.C.i.2.1 The individual is experiencing significant distress or impairment in



this criterion.)

OR

OS.C.i.1.1 The individual has a persistent disorder according to the most recent



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OS.C.i.3. The individual’s internal resources, home environment, family resources, and


individual.

OS.C.i.4. With treatment at this level, the individual is capable of following rules, controlling



OS.C.i.5. If the services being proposed have been attempted previously without significant



OS.C.i.6. The place of service meets the Service Setting Criteria for Traditional Outpatient:




OS.C.c.1. The individual continues to meet the treatment initiation criteria each day that


OS.C.c.2. Either:

OS.C.c.2.1 The individual’s GAF is <70.

OR

OS.C.c.2.2 The individual has a persistent disorder according to the most recent




OS.C.c.3. There is an individualized plan of active, professionally directed treatment that





OS.C.c.4. The treatment goals, interventions, time frames, anticipated outcomes, discharge



OS.C.c.5. Treatment is being rendered in a timely and appropriately progressive manner.

OS.C.c.6. There is a progress note by the treating practitioner for each treatment session



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OS.C.c.7. As appropriate, parents, guardians, and/or other members of the individual’s social




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GERIATRIC



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Geriatric Level of Care Criteria



General Criteria


AM.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

AM.G.g.2. The services must be individualized, specific, and consistent with the individual’s


AM.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

AM.G.g.4. The individual complies with the essential elements of treatment.

AM.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

AM.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


AM.G.g.7. The services are not predominantly domiciliary or custodial.

AM.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



AM.G.i.1. Based on a behavioral health history and mental status evaluation completed by a







intervention.

AM.G.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



AM.G.i.3. As a result of the mental disorder or condition:

AM.G.i.3.1 The individual’s level of functioning has deteriorated such that the



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OR

AM.G.i.3.2 The individual requires an unusual or medically dangerous form of



AM.G.i.4. Continuous skilled behavioral health nursing care, not just twenty-four hour per day



AM.G.i.4.1 The individual is likely to require restraints or seclusion.

OR

AM.G.i.4.2 There is a significant probability that the individual will experience


medications.

OR

AM.G.i.4.3 The individual is, or there is a significant probability that the



AM.G.i.5. If the services being proposed have been attempted previously without significant



AM.G.i.6. The place of service meets the Service Setting Criteria for Acute Inpatient: Mental




AM.G.c.1. The individual continues to meet the treatment initiation criteria each day that


AM.G.c.2. There is an individualized plan of active, professionally directed treatment that


to:

AM.G.c.2.1 Improve or prevent deterioration or delay progression in a clinically




AND


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AM.G.c.2.2 Address a co-morbid substance use disorder or condition, if one

exists.

AM.G.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



AM.G.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

AM.G.c.5. There are daily progress notes by the treating psychiatrist and other appropriate staff


AM.G.c.6. As appropriate, family members, caregivers, and/or other members of the

individual’s social support system are involved in the individual’s treatment.


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General Criteria


AS.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

AS.G.g.2. The services must be individualized, specific, and consistent with the individual’s


AS.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

AS.G.g.4. The individual complies with the essential elements of treatment.

AS.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

AS.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


AS.G.g.7. The services are not predominantly domiciliary or custodial.

AS.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



AS.G.i.1. Based on a behavioral health history and mental status evaluation completed by a

psychiatrist, physician qualified in addiction medicine or by a behavioral health







intervention.

AS.G.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



AS.G.i.3. The individual is dependent on a class or classes and quantity or quantities of




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AS.G.i.4. Continuous skilled behavioral health nursing care, not just twenty-four hour per day



AS.G.i.4.1 The individual has a history of medically complicated detoxification

episodes.

OR

AS.G.i.4.2 The individual has unstable vital signs not treatable on an outpatient

basis.

OR

AS.G.i.4.3 The individual has a medical co-morbidity that significantly increases



AS.G.i.5. The place of service meets the Service Setting Criteria for Acute Inpatient:




AS.G.c.1. The individual continues to meet the treatment initiation criteria each day that


AS.G.c.2. There is an individualized plan of active, professionally directed treatment that


AS.G.c.2.1 Detoxify the individual from the substances requiring a medical

detoxification.

AND

AS.G.c.2.2 Address a co-morbid mental health disorder or condition, if one

exists.

AS.G.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



AS.G.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

AS.G.c.5. There are daily progress notes by the treating psychiatrist or physician qualified in



AS.G.c.6. As appropriate, family members, caregivers, and/or other members of the



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General Criteria


OB.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

OB.G.g.2. The services must be individualized, specific, and consistent with the individual’s


OB.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

OB.G.g.4. The individual complies with the essential elements of treatment.

OB.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

OB.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


OB.G.g.7. The services are not predominantly domiciliary or custodial.

OB.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



OB.G.i.1. Based on a behavioral health history and mental status evaluation completed by a









OB.G.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



OB.G.i.3. As a result of the mental or substance related disorder or condition:

OB.G.i.3.1 The individual’s level of functioning has deteriorated such that the



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OR

OB.G.i.3.2 The individual is dependent on a class or classes and quantity or



OB.G.i.4. Continuous skilled behavioral health nursing care, not just twenty-four hour per day



OB.G.i.4.1 The individual is likely to require restraints or seclusion.

OR

OB.G.i.4.2 The individual has experienced, or there is a significant likelihood



OR

OB.G.i.4.3 The individual has a history of medically complicated detoxification

episodes.

OR

OB.G.i.4.4 The individual has unstable vital signs not treatable on an outpatient



OR

OB.G.i.4.5 The individual has a medical co-morbidity that significantly increases



OB.G.i.5. The individual’s presentation may stabilize, improve, or resolve making treatment at

a lower level of care possible within 23 hours.

OB.G.i.6. The place of service meets the Service Setting Criteria for 23-hour Inpatient





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General Criteria


SM.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

SM.G.g.2. The services must be individualized, specific, and consistent with the individual’s


SM.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

SM.G.g.4. The individual complies with the essential elements of treatment.

SM.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

SM.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


SM.G.g.7. The services are not predominantly domiciliary or custodial.

SM.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



SM.G.i.1. Based on a behavioral health history and mental status evaluation completed by a







intervention.

SM.G.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



SM.G.i.3. As a result of the mental disorder or condition, the individual’s level of functioning





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SM.G.i.4. The individual is not capable of controlling behaviors, providing for his/her own

basic self-care needs or seeking professional help with the structure and support

available from the individual’s family, caregiver, and community support system

and therefore requires treatment in a structured setting providing twenty-four hour

per day supervision by trained personnel.

SM.G.i.5. There is a substantial probability of initiation of acute inpatient treatment in the


SM.G.i.6. If the services being proposed have been attempted previously without significant



SM.G.i.7. The place of service meets the Service Setting Criteria for Sub-Acute Inpatient




SM.G.c.1. The individual continues to meet the treatment initiation criteria each day that


SM.G.c.2. There is an individualized plan of active, professionally directed treatment that


to:

SM.G.c.2.1 Improve or prevent deterioration or delay progression in a clinically




AND

SM.G.c.2.2 Address a co-morbid substance use disorder or condition, if one

exists.

SM.G.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge

plan and criteria for discharge are clinically efficient, reasonable and achievable in


SM.G.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

SM.G.c.5. There are daily progress notes by the treating psychiatrist and other appropriate staff


SM.G.c.6. As appropriate, family members, caregivers, and/or other members of the



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General Criteria


SS.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

SS.G.g.2. The services must be individualized, specific, and consistent with the individual’s


SS.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

SS.G.g.4. The individual complies with the essential elements of treatment.

SS.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

SS.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


SS.G.g.7. The services are not predominantly domiciliary or custodial.

SS.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



SS.G.i.1. Based on a behavioral health history and mental status evaluation completed by a








intervention.

SS.G.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



SS.G.i.3. If the services being proposed have been attempted previously without significant




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SS.G.i.4. The place of service meets the Service Setting Criteria for Sub-Acute Inpatient



SS.G.i.5. The individual is dependent on a class or classes and quantity or quantities of


Detoxification on page 167) and the individual’s residential environment does not

provide the supervision, support, or access to therapeutic services necessary for

outpatient detoxification.

SS.G.i.6. The individual is seriously medically compromised and risks significant acute


controlling substance use with the structure and support available from the

individual’s family, caregiver, and community support system and therefore

requires twenty-four hour per day staff supervision.

SS.G.i.7. There is significant impairment in the individual’s social, occupational, or role

functioning as a result of the substance dependence and there is a clinically credible

rationale for why treatment in a structured setting with twenty-four hour per day

staff supervision will substantially reverse the impairment in social, occupational, or

role functioning.



SS.G.c.1. The individual continues to meet the treatment initiation criteria each day that


SS.G.c.2. There is an individualized plan of active, professionally directed treatment that


SS.G.c.2.1 Detoxify the individual from the substances requiring a medical

detoxification.

OR

SS.G.c.2.2 Improve or prevent deterioration or delay progression in a clinically



of treatment.

AND

SS.G.c.2.3 Address a co-morbid mental health disorder or condition, if one

exists.

SS.G.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge




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SS.G.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

SS.G.c.5. There are daily progress notes by the treating psychiatrist or physician qualified in



SS.G.c.6. As appropriate, family members, caregivers, and/or other members of the



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RESPITE INPATIENT CARE: MENTAL HEALTH

General Criteria


RM.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

RM.G.g.2. The services must be individualized, specific, and consistent with the individual’s


RM.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

RM.G.g.4. The individual complies with the essential elements of treatment.

RM.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

RM.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


RM.G.g.7. The services are not predominantly domiciliary or custodial.

RM.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



RM.G.i.1. Based on a behavioral health history and mental status evaluation completed by a







intervention.

RM.G.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



RM.G.i.3. Respite inpatient care combined with active behavioral health treatment can:

RM.G.i.3.1 Stabilize or improve the individual’s social functioning permitting the

individual to live safely in the community, either independently or in

a supported living setting.


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OR

RM.G.i.3.2 Maintain the individual’s social functioning when a previously

adequate external support system or living situation has become

unstable or is likely to become unstable permitting the individual to

subsequently return to a previously stable living situation.

RM.G.i.4. The individual does not have adequate internal resources or an adequate external

support system to maintain functioning without the structure of respite inpatient

care.

RM.G.i.5. The individual is capable of following rules, controlling behaviors, and seeking


respite inpatient program.

RM.G.i.6. There is a substantial probability of initiation of acute inpatient treatment in the

absence of respite inpatient care.

RM.G.i.7. If the services being proposed have been attempted previously without significant



RM.G.i.8. The place of service meets the Service Setting Criteria for Respite Inpatient: Mental




RM.G.c.1. The individual continues to meet the treatment initiation criteria each day that


RM.G.c.2. There is an individualized habilitation or rehabilitation plan that specifies the goals,



mental disorder or condition that necessitated initiation of treatment.

RM.G.c.3. The habilitation or rehabilitation goals, interventions, time frames, anticipated


reasonable, and achievable in the length of stay typically associated with care at this

level.

RM.G.c.4. Habilitation or rehabilitation services are being rendered in a timely and


RM.G.c.5. There are daily progress notes by the treating psychiatrist and other appropriate staff


RM.G.c.6. As appropriate, family members, caregivers and/or other members of the



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General Criteria


CR.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

CR.G.g.2. The services must be individualized, specific, and consistent with the individual’s


CR.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

CR.G.g.4. The individual complies with the essential elements of treatment.

CR.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

CR.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


CR.G.g.7. The services are not predominantly domiciliary or custodial.

CR.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



CR.G.i.1. The individual has a primary diagnosis of a mental disorder according to the most



CR.G.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



CR.G.i.3. As a result of the mental disorder, the individual’s social functioning has become


CR.G.i.3.1 The individual is, or is likely to become, a danger to self, a danger to


serious self-harm.

OR

CR.G.i.3.2 The individual will require initiation of a higher level of care if



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CR.G.i.4. Supervised residential care combined with active behavioral health treatment can


live safely in the community, either independently or in a supported living setting.

CR.G.i.5. The individual does not have adequate internal resources or an adequate external

support system to maintain functioning with outpatient services in the absence of the

structure of supervised community residential care.

CR.G.i.6. The individual is capable of following rules, controlling behaviors, and seeking

assistance from staff or other professionals as needed within the structure of a


CR.G.i.7. If the services being proposed have been attempted previously without significant



CR.G.i.8. The place of service meets the Service Setting Criteria for Supervised Community




CR.G.c.1. The individual continues to meet the treatment initiation criteria each day that


CR.G.c.2. There is an individualized habilitation or rehabilitation plan that specifies the goals,


prevent deterioration or delay progression in a clinically meaningful way of the

impairment in functioning resulting from the mental disorder that necessitated


CR.G.c.3. The habilitation or rehabilitation goals, interventions, time frames, anticipated



at this level.

CR.G.c.4. Habilitation or rehabilitation services are being rendered in a timely and


CR.G.c.5. There are periodic progress notes by appropriate professional and non-professional


CR.G.c.6. As appropriate, family members, caregivers, and/or other members of the

individual’s social support system are involved in the individual’s treatment or

appropriate efforts are made to enhance or develop the individual’s social support

system.


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General Criteria


PM.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

PM.G.g.2. The services must be individualized, specific, and consistent with the individual’s


PM.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

PM.G.g.4. The individual complies with the essential elements of treatment.

PM.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

PM.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


PM.G.g.7. The services are not predominantly domiciliary or custodial.

PM.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



PM.G.i.1. Based on a behavioral health history and mental status evaluation completed by a







intervention.

PM.G.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



PM.G.i.3. The individual does not have adequate internal resources or an adequate external



care.


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PM.G.i.4. With treatment at this level, the individual is capable of following rules, controlling



PM.G.i.5. If the services being proposed have been attempted previously without significant



PM.G.i.6. The place of service meets the Service Setting Criteria for Partial Hospital



PM.G.i.7. As a result of the mental disorder or condition, the individual is now a clear and



PM.G.i.8. As a result of the mental disorder or condition:

PM.G.i.8.1 The individual demonstrates significant impairment in social,

occupational, or role functioning that represents a deterioration in

level of functioning.

AND

PM.G.i.8.2 The individual has participated in and failed a substantial course of


OR

PM.G.i.8.3 It is clinically probable that the individual will require treatment at a




PM.G.c.1. The individual continues to meet the treatment initiation criteria each day that


PM.G.c.2. There is an individualized plan of active, professionally directed treatment that


to:

PM.G.c.2.1 Improve or prevent deterioration or delay progression in a clinically




AND

PM.G.c.2.2 Address a co-morbid substance use disorder or condition, if one

exists.


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PM.G.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



PM.G.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

PM.G.c.5. Each day the individual receives services there are progress notes by appropriate



response.

PM.G.c.6. As appropriate, family members, caregivers, and/or other members of the



system.


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General Criteria


PS.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

PS.G.g.2. The services must be individualized, specific, and consistent with the individual’s


PS.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

PS.G.g.4. The individual complies with the essential elements of treatment.

PS.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

PS.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


PS.G.g.7. The services are not predominantly domiciliary or custodial.

PS.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



PS.G.i.1. Based on a behavioral health history and mental status evaluation completed by a








intervention.

PS.G.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical



PS.G.i.3. The individual does not have adequate internal resources or an adequate external



care.


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PS.G.i.4. With treatment at this level, the individual is capable of following rules, controlling



PS.G.i.5. If the services being proposed have been attempted previously without significant



PS.G.i.6. The place of service meets the Service Setting Criteria for Partial Hospital



PS.G.i.7. The individual is dependent on a class or classes and quantity or quantities of




PS.G.i.8. The individual has participated in and failed a substantial course of traditional or


PS.G.i.9. It is clinically probable that the individual will require treatment at a higher level of




PS.G.c.1. The individual continues to meet the treatment initiation criteria each day that


PS.G.c.2. There is an individualized plan of active, professionally directed treatment that


PS.G.c.2.1 Detoxify the individual from the substances requiring a medical

detoxification.

OR

PS.G.c.2.2 Improve or prevent deterioration or delay progression in a clinically



of treatment.

AND

PS.G.c.2.3 Address a co-morbid mental health disorder or condition, if one

exists.

PS.G.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



PS.G.c.4. Treatment is being rendered in a timely and appropriately progressive manner.


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PS.G.c.5. Each day the individual receives services there are progress notes by appropriate




PS.G.c.6. As appropriate, family members, caregivers, and/or other members of the



system.


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General Criteria


IM.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

IM.G.g.2. The services must be individualized, specific, and consistent with the individual’s


IM.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

IM.G.g.4. The individual complies with the essential elements of treatment.

IM.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

IM.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


IM.G.g.7. The services are not predominantly domiciliary or custodial.

IM.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



IM.G.i.1. Based on a behavioral health history and mental status evaluation completed by a







IM.G.i.2. The individual’s internal resources, home environment, family resources, and



IM.G.i.3. With treatment at this level, the individual is capable of following rules, controlling




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IM.G.i.4. If the services being proposed have been attempted previously without significant



IM.G.i.5. The place of service meets the Service Setting Criteria for Intensive Outpatient:



IM.G.i.6. As a result of the mental disorder or condition, the individual is a danger to self,


contacts per week.

IM.G.i.7. As a result of the mental disorder or condition, the individual demonstrates

significant impairment in social, occupational, or role functioning and it is clinically

probable that without multiple therapeutic contacts per week the individual’s level

of functioning would decline necessitating treatment at a higher level of care.



IM.G.c.1. The individual continues to meet the treatment initiation criteria each day that


IM.G.c.2. There is an individualized plan of active, professionally directed treatment that


to:

IM.G.c.2.1 Improve or prevent deterioration or delay progression in a clinically




AND

IM.G.c.2.2 Address a co-morbid substance use disorder or condition, if one

exists.

IM.G.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



IM.G.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

IM.G.c.5. Each day the individual receives services there are progress notes by appropriate



IM.G.c.6. As appropriate, family members, caregivers, and/or other members of the



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system.


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General Criteria


IS.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

IS.G.g.2. The services must be individualized, specific, and consistent with the individual’s


IS.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

IS.G.g.4. The individual complies with the essential elements of treatment.

IS.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

IS.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


IS.G.g.7. The services are not predominantly domiciliary or custodial.

IS.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



IS.G.i.1. Based on a behavioral health history and mental status evaluation completed by a







IS.G.i.2. The individual’s internal resources, home environment, family resources, and



IS.G.i.3. With treatment at this level, the individual is capable of following rules, controlling




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IS.G.i.4. If the services being proposed have been attempted previously without significant



IS.G.i.5. The place of service meets the Service Setting Criteria for Intensive Outpatient:



IS.G.i.6. The individual is dependent on a class or classes and quantity or quantities of




IS.G.i.7. The individual has participated in and failed a substantial course of traditional


IS.G.i.8. It is clinically probable that without multiple therapeutic contacts per week the


level of care.



IS.G.c.1. The individual continues to meet the treatment initiation criteria each day that


IS.G.c.2. There is an individualized plan of active, professionally directed treatment that


IS.G.c.2.1 Detoxify the individual from the substances requiring a medical

detoxification

OR

IS.G.c.2.2 Improve or prevent deterioration or delay progression in a clinically




AND

IS.G.c.2.3 Address a co-morbid mental health disorder or condition, if one

exists.

IS.G.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



IS.G.c.4. Treatment is being rendered in a timely and appropriately progressive manner.


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IS.G.c.5. Each day the individual receives services there are progress notes by appropriate



IS.G.c.6. As appropriate, family members, caregivers, and/or other members of the



system.


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General Criteria


CI.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

CI.G.g.2. The services must be individualized, specific, and consistent with the individual’s


CI.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

CI.G.g.4. The individual complies with the essential elements of treatment.

CI.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

CI.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


CI.G.g.7. The services are not predominantly domiciliary or custodial.

CI.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



CI.G.i.1. Based on a behavioral health history and mental status evaluation completed by a


independently prior to, or at the time of initiation of treatment, the individual is





CI.G.i.2. As a result of the mental disorder or condition, the individual has recently developed




CI.G.i.3. It is clinically probable that the individual’s symptoms can be improved or




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CI.G.i.4. The individual does not have adequate internal resources or an adequate external

support system to maintain functioning without the addition of intensive treatment.

CI.G.i.5. With treatment at this level, the individual is capable of following rules, controlling


social support system.

CI.G.i.6. If the services being proposed have been attempted previously without significant



CI.G.i.7. The place of service meets the Service Setting Criteria for Outpatient Crisis




CI.G.c.1. The individual continues to meet the treatment initiation criteria each day that


CI.G.c.2. There is an individualized plan of active, professionally directed treatment that




CI.G.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



CI.G.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

CI.G.c.5. It remains clinically probable that acute treatment at a higher level of care can be

avoided.

CI.G.c.6. There is a progress note by the treating practitioner for each treatment session


CI.G.c.7. As appropriate, family members, caregivers, and/or other members of the

individual’s social support system are involved in the crisis intervention treatment.


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MOBILE TEAM

General Criteria


MT.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

MT.G.g.2. The services must be individualized, specific, and consistent with the individual’s


MT.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

MT.G.g.4. The individual complies with the essential elements of treatment.

MT.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

MT.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


MT.G.g.7. The services are not predominantly domiciliary or custodial.

MT.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



MT.G.i.1. Based on a behavioral health history and mental status evaluation completed by a


independently prior to, or at the time of the mobile team’s visit, the individual is





MT.G.i.2. As a result of the mental disorder, the individual is at imminent risk for treatment at

a higher level of care because the individual is a danger to self, a danger to others,

or demonstrates a rapid deterioration in ability to provide for basic self-care needs.

MT.G.i.3. The individual cannot, or will not agree to, be transported to a formal treatment

setting but the individual, or the individual’s surrogate decision-maker, agrees to at-

home evaluation and/or treatment by the mobile team.

MT.G.i.4. It is clinically probable that treatment at a higher level of care can be avoided with



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MT.G.i.5. The individual does not have adequate internal resources or an adequate external

support system to maintain functioning without the support of mobile team

treatment.

MT.G.i.6. With treatment at this level, the individual’s danger to self, danger to others or


managed.

MT.G.i.7. If the services being proposed have been attempted previously without significant



MT.G.i.8. The service being provided meets the Service Setting Criteria for Mobile Team as




MT.G.c.1. The individual continues to meet the treatment initiation criteria each day that


MT.G.c.2. There is an individualized plan of active, professionally directed treatment that




MT.G.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



MT.G.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

MT.G.c.5. It remains clinically probable that treatment at a higher level of care can be avoided.

MT.G.c.6. There is a progress note by the treating practitioner for each treatment session


MT.G.c.7. As appropriate, family members, caregivers, and/or other members of the



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General Criteria


HH.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

HH.G.g.2. The services must be individualized, specific, and consistent with the individual’s


HH.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

HH.G.g.4. The individual complies with the essential elements of treatment.

HH.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

HH.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


HH.G.g.7. The services are not predominantly domiciliary or custodial.

HH.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



HH.G.i.1. Based on a behavioral health history and mental status evaluation completed by a




mental disorder according or condition to the most recent version of the Diagnostic



HH.G.i.2. As a result of the mental disorder or condition, the individual is now, or is likely to



HH.G.i.3. Either:

HH.G.i.3.1 The individual is unable to leave home for treatment and the

individual, or the individual’s guardian, agrees to home health

services.

OR


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HH.G.i.3.2 The individual is able but unwilling to leave home for treatment; and

the individual or the individual’s surrogate decision-maker agrees to

home health services; and it is clinically probable that treatment at a

higher level of care can be avoided with home health services.

OR

HH.G.i.3.3 Evaluation and treatment in the home setting is likely to increase the


HH.G.i.4. The individual does not have adequate internal resources or an adequate external

support system to maintain functioning without home health services.

HH.G.i.5. The individual’s actual or potential danger to self, danger to others or deterioration



HH.G.i.6. If the services being proposed have been attempted previously without significant



HH.G.i.7. The service being provided meets the Service Setting Criteria for Home Health




HH.G.c.1. The individual continues to meet the treatment initiation criteria each day that


HH.G.c.2. There is an individualized plan of active, professionally directed treatment that





HH.G.c.3. The treatment goals, interventions, time frames, anticipated outcomes, discharge



HH.G.c.4. Treatment is being rendered in a timely and appropriately progressive manner.

HH.G.c.5. There is a progress note by the treating practitioner for each home health visit


HH.G.c.6. As appropriate, family members, caregivers, and/or other members of the



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General Criteria


OM.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

OM.G.g.2. The services must be individualized, specific, and consistent with the individual’s


OM.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

OM.G.g.4. The individual complies with the essential elements of treatment.

OM.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

OM.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


OM.G.g.7. The services are not predominantly domiciliary or custodial.

OM.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



OM.G.i.1. Based on a behavioral health history and mental status evaluation completed by a







OM.G.i.2. As a result of the mental disorder or condition:

OM.G.i.2.1 The individual is experiencing significant distress or impairment in

social, occupational, or role functioning. (Transient, expected

reactions to psychosocial stressors are not sufficient to meet this

criterion.)

OR

OM.G.i.2.2 The individual has a persistent disorder according to the most recent



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OM.G.i.3. The individual has adequate internal resources or an adequate external support


program.

OM.G.i.4. With treatment at this level, the individual is capable of following rules, controlling



OM.G.i.5. If the services being proposed have been attempted previously without significant



OM.G.i.6. The place of service meets the Service Setting Criteria for Traditional Outpatient:




OM.G.c.1. The individual continues to meet the treatment initiation criteria each day that


OM.G.c.2. Either:

OM.G.c.2.1 The individual’s GAF is <70.

OR

OM.G.c.2.2 The individual has a persistent disorder according to the most recent




OM.G.c.3. There is an individualized plan of active, professionally directed treatment that





OM.G.c.4. The treatment goals, interventions, time frames, anticipated outcomes, discharge



OM.G.c.5. Treatment is being rendered in a timely and appropriately progressive manner.

OM.G.c.6. There is a progress note by the treating practitioner for each treatment session


OM.G.c.7. As appropriate, family members, caregivers, and/or other members of the



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system.

OM.G.c.8. The individual demonstrates the ability to meaningfully recall therapeutic

discussions from session to session.


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General Criteria


OS.G.g.1. The services must be consistent with nationally accepted standards of medical

practice.

OS.G.g.2. The services must be individualized, specific, and consistent with the individual’s


OS.G.g.3. The services must be reasonably expected to help restore or maintain the





episode of care.

OS.G.g.4. The individual complies with the essential elements of treatment.

OS.G.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

OS.G.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


OS.G.g.7. The services are not predominantly domiciliary or custodial.

OS.G.g.8. No exclusionary criteria of the health plan or benefit package are met.



OS.G.i.1. Based on a behavioral health history and mental status evaluation completed by a







OS.G.i.2. As a result of the substance related disorder or condition:

OS.G.i.2.1 The individual is experiencing significant distress or impairment in

social, occupational, or role functioning. (Transient, expected

reactions to psychosocial stressors are not sufficient to meet this

criterion.)

OR

OS.G.i.2.2 The individual has a persistent disorder according to the most recent



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OS.G.i.3. The individual has adequate internal resources or an adequate external support


program.

OS.G.i.4. With treatment at this level, the individual is capable of following rules, controlling



OS.G.i.5. If the services being proposed have been attempted previously without significant



OS.G.i.6. The place of service meets the Service Setting Criteria for Traditional Outpatient:




OS.G.c.1. The individual continues to meet the treatment initiation criteria each day that


OS.G.c.2. Either:

OS.G.c.2.1 The individual’s GAF is <70.

OR

OS.G.c.1.1 The individual has a persistent disorder according to the most recent




OS.G.c.3. There is an individualized plan of active, professionally directed treatment that





OS.G.c.4. The treatment goals, interventions, time frames, anticipated outcomes, discharge



OS.G.c.5. Treatment is being rendered in a timely and appropriately progressive manner.

OS.G.c.6. There is a progress note by the treating practitioner for each treatment session


OS.G.c.7. As appropriate, family members, caregivers, and/or other members of the



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system.

OS.G.c.8. The individual demonstrates the ability to meaningfully recall therapeutic

discussions from session to session.


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ADDITIONAL

CLINICAL CRITERIA


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Additional Clinical Criteria


PSYCHOLOGICAL AND NEUROPSYCHOLOGICAL TESTING

This set of criteria addresses psychological and neuropsychological testing as components of

behavioral health treatment for individuals who have, or are suspected of having, behavioral

disorders or conditions as described in the current version of Diagnostic and Statistical Manual

of Mental Disorders. When used in this context, psychological and neuropsychological testing

are used to clarify diagnoses and/or to assist in treatment planning.

Psychological and neuropsychological testing have valid uses unrelated to the provision of

behavioral health treatment for individuals with known or suspected behavioral disorders or

conditions. This set of criteria does not address the medical necessity of psychological and

neuropsychological testing related to the diagnosis or treatment of non-behavioral medical

conditions. These conditions include, but are not limited to, brain tumors, brain injury, seizure

disorders and migraine headaches.

In addition, psychological and neuropsychological testing may be administered to individuals

with known or suspected behavioral disorders or conditions in circumstances unrelated to the

provision of behavioral health treatment. Under such circumstances, psychological and

neuropsychological testing may not be a covered benefit. Testing is customarily not covered in

circumstances where:

The testing is a routine part of an intake assessment and does not otherwise meet the criteria

described below.

The testing results are intended for predominantly academic purposes.

The testing results are for rehabilitative purposes related to non-behavioral medical

conditions.

The testing is part of a disability determination.

The testing is solely the result of litigation or a court order.

The same or an equivalent type of testing can, or is mandated to, be provided by another

organization or institution with which the individual is involved (for example, a school,

employer or governmental organization).


All of the following Psychological and Neuropsychological Service Setting Criteria are required.

PT.1. Psychological and neuropsychological testing is provided only by behavioral health

professionals licensed, certified or registered to practice independently and trained

to administer the appropriate assessment instruments.

PT.2. Psychological or neuropsychological testing is only performed to the extent

necessary to answer the referral question(s).

PT.3. Valid, reliable, and appropriate instruments are used to efficiently answer the

referral question(s) or to assist in determining whether or not additional

psychological testing is medically necessary.


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PT.4. The choice of psychological or neuropsychological testing instruments is based on

the unique clinical presentation of the individual and the specific referral

question(s).

PT.5. The most current versions of tests supported by scientific research and for which

appropriate normative information is available are used.

General Criteria


PT.g.1. The services must be consistent with nationally accepted standards of medical

practice.

PT.g.2. The services must be individualized, specific, and consistent with the individual’s

signs, symptoms, history and diagnosis.

PT.g.3. The services must be reasonably expected to help restore or maintain the

individual’s health, improve or prevent deterioration in the individual’s behavioral




episode of care.

When applied to psychological and neuropsychological testing, this criterion is

interpreted to mean that the results of the testing should be reasonably expected to

meaningfully impact or direct treatment or treatment planning.

PT.g.4. The individual complies with the essential elements of treatment.


interpreted to mean that there is a reasonable expectation that the individual can

and will cooperate with the testing.

PT.g.5. The services are not primarily for the convenience of the individual, provider, or

another party.

PT.g.6. Services are not being sought as a way to potentially avoid legal proceedings,


PT.g.7. The services are not predominantly domiciliary or custodial.


interpreted to mean that testing is not being provided when use of other services is

limited to domiciliary or custodial settings and no additional treatment services are

planned.

PT.g.8. No exclusionary criteria of the health plan or benefit package are met.


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PT.i.1. Based on a behavioral health history and mental status evaluation completed by a


independently prior to testing, the individual is diagnosed as having, or there is

strong presumptive evidence that the individual has a diagnosis of, a mental disorder

or condition according to the most recent version of the Diagnostic and Statistical

Manual of Mental Disorders that requires, and is likely to respond to, professional

therapeutic intervention. (The behavioral health history and mental

status evaluation could be conducted by the behavioral health professional

responsible for the testing.)

PT.i.2. As a result of the mental or substance related disorder or condition the individual is

experiencing significant distress or impairment in social, occupational, scholastic or

role functioning. (Transient, expected reactions to psychosocial stressors are not

sufficient to meet this criterion.)

PT.i.3. There are formal tests with sufficient reliability, validity, and sensitivity to address

the diagnostic, treatment planning or functional question(s) posed by the referral

source.

PT.i.4. Other data that may answer the referral question(s) are unavailable, insufficient, or

contradictory.

PT.i.5. The referral question(s) cannot be answered by sources of data, consultation, or

other less intrusive means than psychological or neuropsychological testing.


PT.i.6. There are multiple diagnostic hypotheses and psychological or neuropsychological

testing is the most efficient way to conduct a differential diagnostic assessment.

PT.i.7. There is a suspected Axis II disorder or traits that are interfering with expected

progress in treatment.

PT.i.8. There is a suspected cognitive or organic disturbance that is likely to explain the

individual’s impairment in functioning or ability to benefit from behavioral health

treatment.

PT.i.9. Treatment is not achieving the expected results and appropriate revisions or

alternatives are significantly unclear.

PT.i.10. The psychological or neuropsychological testing will be used for a clearly

articulated purpose that will facilitate the individual’s treatment such as to identify

specific targets for intervention, formulate a differential diagnosis, or develop a

meaningful treatment plan.


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SUBSTANCE USE REQUIRING MEDICAL DETOXIFICATION

When reviewing requests for detoxification three factors must be considered:

1. Is the substance of abuse one that produces withdrawal effects that require a medical

detoxification?

2. If yes, has the individual used large enough quantities of the substance consistently enough

for a long enough period of time to be physiologically dependent on the substance?

3. If yes, what level of care is required to safely complete the detoxification.

The level of care criteria contained in other sections of this manual describe the process for

making level of care decisions regarding detoxification once the decision is made that the

individual requires a medical detoxification. This set of criteria assists in making the

determination of whether or not a medical detoxification is required.

The following substances do not require a medical detoxification because there are no

dangerous physiological sequelae of discontinued use. Individuals abusing or withdrawing from

these substances may require supportive medical care due to the direct physiological effects of

the substances.

1. Amphetamines or similarly acting sympathomimetic amines.

2. Cannabis.

3. Cocaine.

4. Hallucinogens.

5. Inhalants.

6. Nicotine.

7. Phencyclidine (PCP) or similarly acting arylcyclohexylamine.

The following substances require a medical detoxification when used in sufficient quantities for a

sufficient period of time because of their potential to induce dangerous physiological sequelae

when discontinued in dependent individuals.

1. Alcohol.

2. Opioids.

3. Sedatives.

4. Hypnotics.

5. Anxiolytics.


The presence of one of the following Treatment Initiation Criteria is indicative of the need for

Medical Detoxification.

MD.i.1. Daily alcohol consumption for a period of one month in the following quantities:

MD.i.1.1 One pint of 80 proof liquor.

MD.i.1.2 Twelve cans (12 oz. each) of beer.

OR

MD.i.1.3 One-half gallon of wine per day.


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MD.i.2. A history of significant alcohol, sedative, hypnotic, anxiolytic, or opioid ingestion

and current instability in vital signs, such as:

MD.i.2.1 Blood pressure greater than 160mm Hg systolic.

MD.i.2.2 Blood pressure greater than 110mm Hg diastolic.

MD.i.2.3 Pulse greater than 115.

OR

MD.i.2.4 Temperature greater than or equal to 100.6

MD.i.3. A history of significant alcohol, sedative, hypnotic, or anxiolytic ingestion and a

pentobarbital challenge test indicative of a level of tolerance requiring detoxification

(see Shader, R.I., Manual of Psychiatric Therapeutics).

MD.i.4. A past history of physiologically significant withdrawal symptoms on a similar

quantity of abused substance.


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EATING DISORDERS

Randomized controlled clinical trials suggest that some forms of treatment for individuals with

Eating Disorders are more effective than others. No one treatment for Eating Disorders,

however, is clearly superior to all others. Research and guidelines published by professional

associations identify specific signs and symptoms associated with Eating Disorders that are

important in determining the most appropriate level of care.

The Eating Disorder Criteria outlined below are based on the scientific literature. They are

intended to assist individuals consider how specific medical and behavioral signs and symptoms

influence level of care determinations for individuals with Eating Disorders. The Eating

Disorder Criteria should only be used in conjunction with the Level of Care Criteria contained

elsewhere in this Manual and should not be used alone. The Level of Care Criteria address other

important issues which are not diagnosis-specific but which may influence the decision regarding

an appropriate level of care.

Overview of Eating Disorders

A brief overview of eating disorder symptoms and a summary of treatment objectives are

presented below for the purpose of providing background information to individuals who may

have limited familiarity with eating disorders.

Treatment Objectives:

Individuals with eating disorders face a complicated treatment process that may very well

involve a comprehensive system of care utilizing psychiatric, medical and nutritional counseling

services. Treatment objectives should include each of the following:

1. Restore the patient to a healthy weight. Anorexia, in particular, is characterized by

malnutrition and starvation, which can lead to severe weight loss. Although many

individuals with bulimia are not faced with severe weight loss, or weight loss that

compromises them medically, weight gain may also be a treatment objective when treating

individuals with Bulimia. Attaining a healthy weight is inhibited by a fear of weight gain

and by distorted perceptions and cognitions related to body image, the self, and food.

Whether weight is a treatment objective is determined on the basis of the difference between

an individual’s current weight and an estimation of the individual’s ideal healthy weight.

Ideal healthy weights are determined by a complex interplay of body build, body

composition and other physiological variables. Nonetheless, clinicians commonly use

simpler algorithms based on height, age and sex to estimate normative weight. Weight

thresholds should be considered estimates based on these norms, not absolutes. The Body

Mass Index (BMI) is also used to characterize an individual’s weight. BMI is calculated by

dividing the individual’s weight in kilograms by the square of the individual’s height in

meters (BMI = kg/m2). Consideration should be given to the clinician’s assessment of the

individual’s weight relative to healthy weight.

Rate of weight loss may be as important a consideration in determining a need for care as is

weight itself but objective criteria for using rate of weight loss in determining level of care do

not yet exist. For children and adolescents, rate of weight loss, regardless of healthy weight,


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should be considered, particularly when weight loss is accompanied by a refusal to eat.

Again, consideration should be given to the clinician’s evaluation of weight loss in addition

to other risk factors that may indicate the need for treatment at a higher level of care.

2. Treat medical complications. Medical complications are a by-product of the disturbed eating

behaviors that include starvation, fasting, purging, vomiting and inadequate intake of

nutrients. The immediate physical complications that can arise from eating disorders are

numerous and can be fatal. These include dehydration, electrolyte imbalance, infection of

salivary glands, constipation, dulled intestinal peristalsis due to laxative abuse, edema,

bloating, caries, erosion of tooth enamel, amenorrhea, endocrine and metabolic problems,

malnutrition, skin and hair abnormalities, and cardiovascular problems. Several serious

medical complications may be irreversible, including growth retardation, impaired

acquisition of peak bone mass during the second decade of life, and increased risk of

osteoporosis in adulthood.

3. Increase patient motivation to cooperate and become invested in treatment. Patient

motivation to enter and participate in treatment is a primary barrier to overcome in the

treatment of individuals with eating disorders. These individuals may be in denial about the

extent to which their behaviors are problematic. Distorted perceptions about food, the self

and body, or feelings about gaining weight may create ambivalence toward treatment.

Weight gain, or a fear of weight gain, may also exacerbate anxiety, depression or other

psychiatric symptoms. An effective and trusting working alliance between a patient and

practitioner should not be underestimated as a critical component to providing effective care.

4. Address disturbed eating behaviors and educate patients about nutrition and eating patterns.

Treatment of individuals with eating disorders may require varying degrees of structure to

ensure that they feed themselves, ingest appropriate and adequate amounts of food and

nutrients, and do not engage in efforts to expel food or burn calories. Some individuals may

be physically unable to feed themselves; others may avoid or restrict ingestion of food.

Individuals with Anorexia or Bulimia may purge food, exercise compulsively or abuse

laxatives or diuretics in an effort to control their weight. The extent to which the individual

can exert self-control over disturbed eating, exercise or purging behaviors relates to the

structure required to help the individual regain control.

All individuals with eating disorders are likely impaired to some extent in their ability to

control eating disorder-related thoughts, which include distorted perceptions and beliefs

about food, eating, and its effect on their bodies. Individuals with Anorexia, in particular,

may exhibit an intense fear of gaining weight or becoming fat and may not accurately

perceive or experience their body weight or shape. As part of treatment, most patients will

likely require education about nutrition, relearning healthy eating behaviors and nutritional

rehabilitation in addition to psychiatric treatment.

5. Address comorbid psychiatric issues. A wide array of comorbid conditions and clinical

features are linked to eating disorders. These include substance use disorders, particularly

among bulimic individuals; depressive-spectrum disorders, especially unipolar depression;

anxiety disorders, most commonly social phobia and OCD; personality disorders, especially


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Cluster C in individuals with anorexia and Cluster B in those with bulimia; borderline

personality disorder (which is associated with poorer treatment outcome); and post-traumatic

stress disorder. These must be addressed in treatment since they may be linked to the

etiology of the disorder or act to sustain the eating disorder. Issues which may be pertinent in

treating persons with eating disorders include developmental issues, formation of identity,

body image concerns, self-esteem, difficulties with sexual and aggressive feelings or

experiences, emotional regulation, family dysfunction, coping styles and problem solving.

Treatment of weight symptoms and disturbed eating behaviors may also exacerbate other

psychiatric issues, including depression and anxiety.

6. Enlist family support and provide family counseling and therapy where appropriate. Family

support is critical to achieving treatment goals and to sustaining them over time. In addition,

problematic family dynamics may also affect an individual’s ability to recover or maintain

recovery. Family therapy should be considered whenever possible, especially when the

patient is still living with or regularly involved with parents.

7. Prevent relapse. Early treatment and maintenance of improvements is clinically optimal and

cost-effective. Treatment for eating disorders may require an extended period of

multidisciplinary care. Complete recovery from the eating disorders over the long term

occurs only in about one third of patients. Other patients achieve varying degrees of

improvement or recover from the eating disorder but experience other psychiatric symptoms

that affect their lives. Maintenance therapy and community resources may be necessary to

help the individual maintain improvements and prevent relapse.

Interventions:

Achieving treatment objectives often requires the use of multiple levels of care. These

objectives may include:

1. Evaluation: A thorough evaluation of the patient’s treatment needs should be completed by

medical and mental health professionals since different medical, nutritional, psychosocial and

psychiatric treatment modalities may be deployed at different points in time.

2. Nutritional rehabilitation: Nutritional rehabilitation should be an integral component of care

received by patients diagnosed with eating disorders. Treatment objectives related to weight

gain, re-education regarding nutrition and eating, and establishment of structured diets are

basic components of nutritional rehabilitation. Weight gain varies by treatment setting and is

impacted by the patient’s motivation. Empirical findings suggest that inpatient treatment

settings can achieve a weight gain of 2-3 lbs per week. Weight gain in inpatient settings may

require nurturing re-feeding programs or forced nasogastric or parenteral feeding when

clinically necessary. Studies of outpatient treatment settings report weight gains of 0.5-1 lb

per week. The urgency with which weight gain is required, patient motivation, and the

availability of services outside an acute inpatient treatment can guide decisions about level of

care. Weight gain can exacerbate psychiatric symptoms, making a concurrent focus on

psychiatric symptoms important.


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3. Psychosocial interventions: Psychosocial interventions cover a full range of mental health

and support services. Although there is concurrence that psychotherapy may play a key role

in the treatment of eating disorders, there is no clear evidence that psychotherapy is

beneficial during acute re-feeding. No one professional treatment modality is more effective

than all others. Different types of treatment may be more beneficial at different junctures in

the treatment.

While there is no consensus about when formal psychotherapy should be initiated,

psychotherapy is not beneficial to individuals who are starved or malnourished to a point

where they cannot cognitively participate in a process of self-examination. Cognitive,

behavioral, and interpersonal interventions can play an important role in maintaining healthy

eating behaviors, changing cognitions about the self, food and eating, and improving coping

strategies. Psychodynamic interventions help the patient address underlying personality

disorders or features, and can foster insight and maturation. No consensus exists around the

utility of group psychotherapy. If group psychotherapy is being considered, individuals

should undergo an evaluation to assess their ability to improve in a group setting before such

treatment is implemented. Family and/or couples psychotherapy are frequently beneficial for

both symptom reduction and for addressing family relational problems that may maintain a

patient’s disturbed eating behaviors.

4. Medication: Individuals with eating disorders may require medication to manage psychiatric

symptoms and maintain weight gain. For individuals with Anorexia, medications are usually

used after weight has been restored. Malnourished depressed patients are more prone to side

effects and less responsive to the beneficial effects of some medications. Antidepressants are

commonly used in the treatment of both Anorexia and Bulimia. In treating Anorexia,

antidepressants are used following weight gain to address psychiatric comorbidity such as

depression, persistent obsessive or compulsive symptoms, and to help individuals maintain

weight. For individuals with Bulimia whose weight may be stable, antidepressants are used

to help reduce the frequency of binging and purging behaviors, and to treat depression.

Other psychotropic medications are also commonly used in the treatment of persons with

eating disorders. These are primarily deployed to treat psychiatric symptoms, which may

include anxiety, obsessive or psychotic thinking, and impulse control difficulties.

Because antidepressants and other medications may lead to weight gain, medication

compliance among individuals with eating disorders is a primary concern. The quality of the

relationship between the physician and patient is critical in helping the patient continue

medication use while learning to manage side effects and tolerate weight gain.

Eating Disorder Criteria

The Eating Disorder Criteria should only be used in conjunction with the Level of Care Criteria.

Level of Care Criteria address other important issues which are not diagnosis-specific but which

may influence the decision regarding an appropriate level of care.

Eating Disorder diagnosis-specific criteria are presented for the treatment at the following levels

of care:

Acute Inpatient Mental Health


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Sub-Acute Inpatient (Residential) Mental Health

Partial Hospital Mental Health

Intensive Outpatient Mental Health

Traditional Outpatient Mental Health

Acute Inpatient Treatment

Acute Inpatient Treatment for Eating Disorders is recommended if ED.AM.1 is met along with

one of ED.AM.2, ED.AM.3, or ED.ED.4.

ED.AM.1. The individual has been diagnosed with an Eating Disorder.

ED.AM.2. Frequent monitoring by skilled nursing staff is required for:

ED.AM.2.1. All age groups due to any of the following:

ED.AM.2.1.1. Temperature less than 97 degrees Fahrenheit.

ED.AM.2.1.2. Electrolyte imbalance.

ED.AM.2.1.3. Dehydration.

ED.AM.2.1.4. Hepatic, renal or cardiovascular organ compromise

requiring acute treatment.

OR

ED.AM.2.1.5. Nasogastric or other special feeding is necessary as a

medical intervention to counter starvation or medical

instability.

ED.AM.2.2. Adults due to any of the following:

ED.AM.2.2.1. A heart rate less than 40 bpm.

ED.AM.2.2.2. Blood pressure less than 90/60 mm Hg.

ED.AM.2.2.3. Glucose less than 60 mg/dl.

OR

ED.AM.2.2.4. Potassium less than 3 meq/liter.

ED.AM.2.3. Children and adolescents due to any of the following:

ED.AM.2.3.1. A heart rate between 40-49 bpm.

ED.AM.2.3.2. Orthostatic blood pressure changes (greater than 20

bpm increase in heart rate, or more than 10-20 mm Hg

drop).

ED.AM.2.3.3. Blood pressure below 80/50 mm Hg.

OR

ED.AM.2.3.4. Hypokalemia or hypophosphatemia.


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ED.AM.3. One of the following weight criteria is met:

ED.AM.3.1. The individual’s weight is rapidly approaching a weight at which,

based on prior history, medical destabilization is likely to occur.

ED.AM.3.2. The individual has had a significant weight decline that continues

despite appropriate treatment at less intense levels of care and the

individual is approaching a weight at which medical destabilization is

likely to occur.

ED.AM.3.3. The individual weighs less than 75% of healthy body weight.

OR

ED.AM.3.4. The individual is a child or adolescent and has experienced an acute,

significant weight decline with food refusal.

ED.AM.4. Either:

ED.AM.4.1. The individual experiences uncontrolled vomiting such that the

individual has lost physical ability to control expulsion of food.

OR

ED.AM.4.2. The individual is at significant risk of being acutely medically

compromised due to the severity of eating, purging or compulsive

exercise behaviors and treatment at a less intense level of care has not

adequately controlled or reduced symptoms.

Sub-Acute Inpatient (Residential) Treatment

Sub-Acute Inpatient (Residential) Treatment for Eating Disorders is recommended if ED.SM.1

and ED.SM.2 and either ED.SM.3 or ED.SM.4 are met.

ED.SM.1. The individual has been diagnosed with an Eating Disorder.

ED.SM.2. Medical status requires daily monitoring but the individual is medically stable.

ED.SM.3. Either:

ED.SM.3.1. The individual weighs between 75% and 85% of his or her healthy

body weight.

OR

ED.SM.3.2. The individual has experienced an acute weight decline despite

appropriate treatment at less intense levels of care and the individual

is at significantly increased risk for medical complications,

worsening condition or a higher level of care.

ED.SM.4. Treatment at a less intense level of care has been unsuccessful in controlling eating,

purging or exercise behaviors and at least one of the following is required to contain

intractable behaviors:

ED.SM.4.1. Supervision during all meals to ensure ingestion of adequate

quantities of food.

ED.SM.4.2. Continuous supervision to prevent compulsive exercise, or laxative

or diuretic abuse.

OR

ED.SM.4.3. Supervision during bathroom use to prevent purging.


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Partial Hospital Treatment

Partial Hospital Treatment for Eating Disorders is recommended if ED.PM.1 and ED.PM.2 and

either ED.PM.3 or ED.PM.4 are met.

ED.PM.1. The individual has been diagnosed with an Eating Disorder.

ED.PM.2. Medical status requires intermittent monitoring but the individual is medically

stable.

ED.PM.3. The individual has experienced a recent significant, though not necessarily acute,

decline in weight to levels substantially below healthy body weight which persists

despite appropriate treatment at less intense levels of care.

ED.PM.4. All of the following behavioral criteria are met:

ED.PM.4.1. The individual presents with longstanding difficulties in controlling

purging behaviors, compulsive exercise, diuretic or laxative abuse

which place the individual at increased risk for medical

complications, significant weight reduction or use of services at a

higher level of care.

ED.PM.4.2. Treatment at a less intense level of care has been unsuccessful in

controlling eating, purging and compulsive exercise behaviors.

AND

ED.PM.4.3. The structure Partial Hospitalization can provide can reduce these

behaviors.

Intensive Outpatient Treatment

Intensive Outpatient Treatment for Eating Disorders is recommended if ED.IM.1 and ED.IM.2

and either ED.IM.3 or ED.IM.4 are met.

ED.IM.1. The individual has been diagnosed with an Eating Disorder.

ED.IM.2. The individual is medically stable.

ED.IM.3. The individual has experienced a recent significant, though not necessarily acute,

decline in weight to levels substantially below healthy body weight which persists

despite appropriate treatment at less intense levels of care.

ED.IM.4. All of the following behavioral criteria are met:

ED.IM.4.1. The individual presents with a significant lack of control over

eating, purging or compulsive exercise behaviors and cognitions.

ED.IM.4.2. An Intensive Outpatient setting can reasonably be expected to

reduce the eating, purging and compulsive exercise behaviors and

cognitions.

AND

ED.IM.4.3. Without a reduction in the eating, purging and compulsive exercise

behaviors and cognitions, the individual is at increased risk for

medical complications, significant reduction in body weight, or use

of services at a higher level of care.


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Traditional Outpatient Treatment

Traditional Outpatient Treatment for Eating Disorders is recommended if ED.OM.1 and

ED.OM.2 and either ED.OM.3 or ED.OM.4 are met.

ED.OM.1. The individual has been diagnosed with an Eating Disorder.

ED.OM.2. The individual is medically stable.

ED.OM.3. The individual has experienced a significant decline in weight, which does not

presently medically compromise the individual though continued weight loss will

likely result in medical compromise.

ED.OM.4. Both of the following behavioral criteria are met:

ED.OM.4.1. With treatment at this level the individual is able to control or

maintain control over eating, purging and compulsive exercise

behaviors and cognitions.

AND

ED.OM.4.2. No history of prior treatment indicates the need for increased structure

to rapidly reduce these behaviors.


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ELECTROCONVULSIVE THERAPY

Electroconvulsive therapy (ECT) was introduced in 1938 and it is still a treatment frequently

chosen by practitioners for severe, debilitating mental disorders. In the past four decades

numerous clinical trials have confirmed the efficacy and clinical relevance of ECT, especially for

severe illnesses characterized by biological features or delusions. ECT is the treatment of choice

when psychopharmacology has failed for severely depressed, manic or psychotic individuals.

ECT has a more rapid onset of action than antidepressant or antipsychotic pharmcotherapeutic

interventions making it a primary consideration for individuals whose symptomatology places

them or others at significant risk of harm. ECT should be strongly considered as a treatment

alternative when an individual presents with severe depression with psychotic features and active

suicidal behavior.

Research has shown that potential side-effects include memory loss, headaches, nausea, and

muscle stiffness. The current clinical and research literature contain a variety of conclusions

regarding the frequency, severity, and duration of cognitive side-effects. Retrograde memory

loss has been reported to last anywhere from 2 weeks to 7 months, while anterograde memory

loss is reported to recover rapidly.

Research has shown that bilateral titrated dosing at levels 1.5 – 2.5 times above the seizure

threshold is effective. Fewer cognitive side-effects have been observed in treatment schedules of

two- to three-times-weekly over the course of nine to twelve sessions. Research has shown that

unilateral non-dominant ECT yields less severe cognitive side-effects, as well as less effective

treatment.

Research suggests that the clinical condition of the patient should aid in determining ECT dosing

and frequency. For example, patients that present with imminent danger or harm to self or other

may require a more frequent dosing regimen.

The Electroconvulsive Therapy Criteria are intended to assist in making authorization decisions

for this treatment modality. When reviewing requests for ECT the following factors should be

considered:

1. Is the clinical condition one that is likely to respond to ECT?

2. What is the rationale for selecting ECT over other options? (Have other options failed, for

example, or is rapid onset of action a primary clinical concern?)

3. Do any contraindications to the use of ECT exist?

4. What level of care is required to safely treat the individual?

The level of care decision is separate from the decision to authorize ECT as a treatment

modality. Uncomplicated ECT can safely be provided in an ambulatory setting. Level of care

decisions are based on the individual’s clinical condition, not on the choice of ECT as a

treatment modality. The Level of Care Criteria contained in other sections of this Manual

address the principles and criteria for making level of care decisions. This set of criteria assists

in making the determination of whether or not ECT should be authorized.


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In rare instances, ECT that was planned in an ambulatory setting may require inpatient admission

if the individual’s reaction to the treatment prevents safe discharge. For example, the individual

remains unusually confused many hours after completing treatment. This situation is not unlike

instances where surgical procedures are scheduled as outpatient procedures but the individual’s

post-procedure condition necessitates inpatient admission.


The presence of one of the following Treatment Initiation Criteria is indicative of the

appropriateness of Electroconvulsive Therapy.

ET.i.1. The individual has a history of Major Depressive Disorder that has not responded

well to adequate trials of pharmacologic treatment and presents with signs and

symptoms consistent with a recurrent episode of Major Depressive Disorder.

ET.i.2. The individual has been treated with ECT for Major Depressive Disorder in the past,

is diagnosed with a recurrent episode of Major Depressive Disorder, and prefers

ECT to pharmacologic treatment.

ET.i.3. The individual is diagnosed with Major Depressive Disorder that has not responded

to adequate trials of pharmacologic treatment.

ET.i.4. The individual presents with Major Depressive Disorder resulting in behaviors that

put the individual or others at significant risk of harm (such as that resulting from

acting on suicidal or paranoid ideation) that need to be ameliorated as quickly as

possible.

ET.i.5. The individual presents with severe Mania resulting in behaviors that put the

individual or others at significant risk of harm (such as that resulting from

exhaustion or physically harming others) not responsive to pharmacologic

intervention.

ET.i.6. The individual presents with chronic or recurrent aggression not responsive to

pharmcotherapeutic intervention.

ET.i.7. The individual presents with Schizophrenia with affective or catatonic symptoms

not responsive to pharmacologic intervention.

ET.i.8. The individual presents with Schizophrenia with affective symptoms resulting in

behaviors that put the individual or others at significant risk of harm (such as that

resulting from acting on suicidal or paranoid ideation) that need to be ameliorated as

quickly as possible.

ET.i.9. The individual presents with Catatonia not responsive to pharmacologic

intervention.

ET.i.10. The individual, especially an older adult, is not able to tolerate the side effects of

pharmacologic agents (for example cardiovascular, genitourinary, or central nervous

system side effects).

ET.i.11. The individual is pregnant and the safety of the fetus from pharmacologic

intervention is a significant concern.


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Exclusionary Criteria

The presence of one of the following Exclusionary Criteria is typically a contraindication for

ECT.

ET.x.1. The individual has an intracranial space occupying lesion with increased intracranial

pressure

ET.x.2. The individual has had a cerebrovascular accident within the last month.

ET.x.3. The individual has a bleeding or unstable vascular aneurism or abnormality.

ET.x.4. The individual has a retinal detachment.

ET.x.5. The individual has a significant cardiovascular problem including recent myocardial

infarction, severe cardiac ischemia, and significant hypertension (including

pheochromocytoma).


The presence of one of the following Treatment Continuation Criteria is required throughout the

ECT treatment episode.

ET.c.1. The individual has had an initial positive response to ECT and completion of a

course of treatment is clinically indicated. A typical course of ECT for treatment of

Major Depressive Disorder is 2 to 3 times weekly administered over 9 to 12

sessions.

ET.c.2. The individual was successfully treated with ECT for Major Depressive Disorder

and maintenance treatment with ECT is indicated because of one of the following:

ET.c.2.1. The individual has not responded favorably to adequate trials of

antidepressant medications in the past.

ET.c.2.2. The individual has had reoccurrences of Major Depressive Disorder

while taking adequate dosages of maintenance antidepressant

medication.

ET.c.2.3. Antidepressant medications are medically contraindicated.

.


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APPLIED BEHAVIOR ANALYSIS: OUTPATIENT TREATMENT

In some states, law and/or regulation require coverage of Applied Behavior Analysis (ABA)

under specified circumstances. While these criteria are intended to accommodate such legal

requirements, to the extent that there are any discrepancies, applicable law and regulation

would take precedence. In the absence of applicable law and/or regulation, coverage for ABA

would be dependent on the health plan’s determination that ABA is not an experimental or

investigational treatment.

Under some circumstances, ABA may be considered an educational intervention. This is more

likely to be the case when target behaviors relate to communication or interaction with others,

rather than behaviors that pose a risk to self or others. Under these circumstances coverage

would likely be determined by the health plan’s coverage of educational interventions even if

ABA is not specifically mentioned in the certificate of coverage or equivalent.

These criteria focus on ABA provided in an outpatient setting. In an inpatient setting providing

multi-modal therapy, ABA, if used, would likely be one of numerous interventions and would

typically not be individually authorized.



AB.i.1. ABA is potentially a covered treatment for the individual because either:

AB.i.1.1. There is a legal mandate (typically a state law or regulation) for

coverage of ABA under some circumstances.

OR

AB.i.1.2. The health plan has determined3 that ABA is an approved treatment

for at least one indication.

AND

AB.i.1.3. The individual’s certificate of coverage or equivalent does not

exclude ABA.

AB.i.2. Based on a behavioral health history and mental status evaluation completed by a


independently prior to initiation of treatment, the individual is diagnosed as having a


and Statistical Manual of Mental Disorders for which ABA is an approved

treatment as determined by either:

AB.i.2.1. Legal mandate.

OR

AB.i.2.2. The organization’s assessment of ABA as a treatment modality.

3 Such determinations can be made using the organization’s standard process for determining if a diagnostic or

treatment procedure is experimental or investigational.


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AB.i.3. The individual is within the age parameters for coverage of ABA established by

either:

AB.i.3.1. Legal mandate.

OR

AB.i.3.2. The organization’s assessment of ABA as a treatment modality.

AB.i.4. As a result of the mental disorder or condition the individual displays a specific,

identified behavior (the target behavior) that is of such severity that either:

AB.i.4.1. The individual’s safety or that of others is jeopardized.

OR

AB.i.4.2. The behavior significantly interferes with the individual’s

development or ability to communicate or interact with peers who are

developing normatively or others in the individual’s environment

such that the individual cannot participate adequately in essential

developmentally-appropriate activities such as school or maintaining

family or social relationships.

AB.i.5. A behavioral health professional licensed, certified, or registered to practice

independently prescribes ABA for the target behavior.

AB.i.6. There are reasonable, professionally-based expectations by a behavioral health

professional licensed, certified, or registered to practice independently that both:

AB.i.6.1. The target behavior is likely to respond to ABA.

AB.i.6.2. The individual will achieve functional gains that are substantively

greater than those expected by growth and maturation.

AB.i.7. A course of less intensive treatment4 has failed to produce measurable improvement

in the target behavior.

AB.i.8. There is a plan of care developed by a Board Certified Behavior Analyst (BCBA),

or the focus of the clinical intervention is to have a BCBA develop a plan of care,

that:

AB.i.8.1. Is individualized.

AB.i.8.2. Is time-limited.

AB.i.8.3. Is consistent with ABA techniques.

AB.i.8.4. Clearly defines (a) specific target behavior(s).

AB.i.8.5. Records frequency, rate, symptom intensity or duration, or other

objective measures of baseline levels.

4 In this context, less intensive treatment refers to traditional outpatient care provided less frequently or with fewer

service hours per time period than is being requested for ABA.


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AB.i.8.6. Describes behavioral intervention techniques appropriate to the target

behavior(s), the reinforcers selected, and strategies for generalization

of learned skills.

AB.i.8.7. Establishes quantifiable criteria for assessing progress.

AB.i.8.8. Incorporates caregiver5 training so that caregivers can provide

additional hours of intervention.

AB.i.8.9. Identifies an appropriate number of professionally-rendered service

hours needed.

AB.i.8.10. Documents discharge criteria and a transition plan.

AB.i.9. The plan of care will be implemented by a Board Certified Behavior Analyst

(BCBA) or by a Board Certified Assistant Behavior Analyst (BCaBA) under the

direct supervision of a BCBA unless legal mandate provides otherwise.

AB.i.10. The professional providers are not family members.

AB.i.11. The individual’s internal resources, home environment, family resources, and


individual.

AB.i.12. If the services being proposed have been attempted previously without significant



AB.i.13. The place of service meets the Service Setting Criteria for Traditional Outpatient:




AB.c.1. The individual continues to meet the treatment initiation criteria each day that


AB.c.2. There is either:

AB.c.2.1. Measurable progress that is maintained beyond the end of the

treatment session and that is generalized outside of the treatment

setting to the individual’s home and social setting.

OR

AB.c.2.2. A reasonable professionally-based expectation by a behavioral health

professional licensed, certified, or registered to practice

independently, taking into account the individual’s clinical history

and recent clinical experience, that continuation of ABA is more

5 As used in this section, “caregiver” is not predominantly or solely intended to mean a paid individual, either

professional or paraprofessional.


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likely than not to result in measurable progress that can be maintained

beyond the end of the treatment session and that can be generalized

outside of the treatment setting to the individual’s home and social

setting.

AB.c.3. The plan of care is implemented as written and is updated as appropriate to the

individual’s progress and the improvement in the skills of the caregiver.

AB.c.4. The plan of care is being be implemented by a Board Certified Behavior Analyst

(BCBA) or by a Board Certified Assistant Behavior Analyst (BCaBA) under the

direct supervision of a BCBA unless legal mandate provides otherwise.

AB.c.5. If the plan of care is being implemented by a BCaBA, supervision by the BCBA

must be documented and must include:

AB.c.5.1. At least one hour of face-to-face supervision by the BCBA of the

BCaBA for each ten hours of behavioral therapy provided by the

BCaBA.

AND

AB.c.5.2. Professional involvement of the BCBA on-site with the individual

receiving treatment at least one hour per month.

AB.c.6. The treatment goals, interventions, time frames, anticipated outcomes, discharge



AB.c.7. Treatment is being rendered in a timely and appropriately progressive manner.

AB.c.8. Treatment is resulting in meaningful improvement of the target behavior that is the

focus of treatment.

AB.c.9. Treatment is not making behaviors worse.

AB.c.10. There is a progress note by the treating practitioner for each treatment session


AB.c.11. Caregivers

AB.c.11.1. Are involved in the individual’s treatment.

AB.c.11.2. Provide additional hours of ABA outside of the professional treatment

setting.

AND

AB.c.11.3. Provide a report of the specific interventions provided outside of the

professional treatment setting which are documented by staff.


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APPENDICES


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Appendices


APPENDIX I: ASSESSING DANGEROUSNESS

If dangerousness to self or others is identified as a precipitant for treatment, an assessment of the

following parameters is necessary to determine the level of dangerousness and thus the

appropriate level of care. A reliable assessment of dangerousness cannot be made on an

individual who is intoxicated on drugs or alcohol. Assessment, and therefore authorization for

treatment, must wait for the intoxication to clear. Usually the patient will need to be held in the

emergency department or in 23-hour inpatient observation status until the assessment can be

completed.

Danger to Self If the patient has made a suicide attempt, medical clearance is necessary

before proceeding with the review.

Assess each of the following areas:

1. Does the individual have a plan?

2. Is the plan lethal?

3. Does the individual intend to carry out the plan?

3.1 Is there termination behavior (for example, disposing of

possessions, creating a new will)?

3.2 Is the individual oriented to the future?

3.3 Is there a family history of suicide or suicide attempts?

4. Does the individual have the means to carry out the plan?

5. Does the individual have a history of suicide attempts?

If the answers to these questions are positive, the individual is likely to

pose a serious risk to self. Authorize treatment accordingly, taking into

consideration whether there are responsible others who are willing and

able to monitor the individual.

If the answers to the questions above are negative, continue to evaluate the

following areas:

1. Is there evidence of psychosis or cognitive impairment?

2. Is there impaired judgment?

3. Is there evidence of unusual behavior?

4. Is the individual depressed?

5. Is the individual experiencing severe guilt or remorse?

6. Is the individual feeling hopeless or helpless?

7. Is the individual severely agitated?


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Appendices


8. Does the individual lack social attachment with others?

9. Does the individual lack parental or peer group support?

10. Is there a lack of communication with parents or peers?

11. Has the individual had a real or perceived catastrophic loss?

12. Has the individual had severe health changes?

13. Has there been the death or separation from family members, peers, or

significant others?

If a combination of these criteria indicate a strong potential for danger to

self, authorize treatment accordingly, taking into consideration whether

there are responsible others who are willing and able to monitor the

individual.


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Appendices


Danger to Others

Assess each of the following areas:

1. Is there a threat of violence to person or property?

2. Is there a specific plan?

3. Is there a reasonable suspicion that the plan may be carried out?

4. Is there evidence of current violence toward others such as:

4.1 High risk: Unprovoked assaults or the use of weapons?

4.2 Medium risk: Fighting, punching, slapping or kicking?

4.3 Low risk: Verbal threats, profanity, or provocation?

5. Is there evidence of current violence to property such as:

5.1 High risk: Breaking objects or setting fires?

5.2 Medium risk: Throwing objects or kicking furniture?

5.3 Low risk: Slamming doors or scattering clothing or property?

6. Does the individual have a history of violence to persons or property?

If the individual has a mental disorder according to the most recent

edition of the Diagnostic and Statistical Manual of Mental Disorders.

AND

The mental disorder is the cause of the presenting symptoms.

AND

There is reason to believe the individual will carry out the threats to

harm others or destroy property.

OR

There is current high-risk behavior.

THEN

The individual is likely to pose a serious risk to others or to property.

Authorize treatment accordingly, taking into consideration whether there

are responsible others who are willing and able to monitor the

individual.

If the individual does not have a mental disorder or the threats to harm

others or property are largely the result of Conduct Disorder or

Antisocial Personality Disorder, a legal or criminal justice intervention

should be considered in response to the threat of violence.


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Appendices


If the disposition is not clear, continue to evaluate the following areas:

1. Is there evidence of psychosis or cognitive impairment?

2. Is there impaired judgment?

3. Is there evidence of unusual behavior?

If there is evidence of psychosis, impaired judgment, or unusual behavior

is the individual medically clear? If not, medical clearance or evaluation

is appropriate.

If medically clear, continue to evaluate the following areas:

1. Is there a history of violence to others?

2. Is there a history of destruction of property?

3. Is there a history of cruelty to animals?

4. If the individual is a minor still living at home:

4.1 Does the individual come from a dysfunctional family?

4.2 Does the individual lack parental or peer support?

4.3 Does the individual lack communication with parents or peers?

4.4 Does the individual have positive social attachments (e.g.

clubs)?

4.5 Does the individual have negative social attachments (e.g.

gangs)?

If a combination of these criteria indicate a strong potential for danger

to others or destruction of property as the result of a mental disorder,

authorize treatment accordingly.


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Appendices


APPENDIX II: DIAGNOSES GENERALLY CONSIDERED TO HAVE A TREATABLE

BIOLOGICAL COMPONENT

Whenever an individual is in treatment for one of the following disorders, strong consideration

should be given early in the course of treatment to arranging a psychiatric evaluation to

determine if a somatic intervention is appropriate.

Schizophrenia and Other Psychotic Disorders

Mood Disorders

Anxiety Disorders

Eating Disorders

Sleep Disorders

Attention Deficit/Hyperactivity Disorder

Tourette’s Disorder

Delirium


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Appendices


APPENDIX III: TREATMENTS GENERALLY EXCLUDED FROM COVERAGE

Though not an exhaustive list, the following treatments are generally excluded from

reimbursement based on lack of empirical and clinical support for their appropriateness or

effectiveness.

Astrological Counseling

Bioenergetic Therapy

Crystal Healing Treatment

Guided Imagery

Megavitamin Therapy

Narcotherapy with LSD

Orthomolecular Therapy

Primal Scream Therapy

Rolfing


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