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
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Medical Necessity Manual for Behavioral Health
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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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Table of Contents
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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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Table of Contents
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Appendix II: Diagnoses Generally Considered To Have A Treatable Biological
Component ...........................................................................................................189 Appendix III: Treatments Generally Excluded From Coverage .....................................190
References ....................................................................................................................................191
Medical Necessity Manual for Behavioral Health
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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.
Medical Necessity Manual for Behavioral Health
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September 1, 2012
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©1998-2012 The Mihalik Group Page vi
PLAN-SPECIFIC AMENDMENTS
Medical Necessity Manual for Behavioral Health
Version 7.0.1
September 1, 2012
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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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INTRODUCTION
Medical Necessity Manual for Behavioral Health
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Introduction
©1998-2012 The Mihalik Group Page 2
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.
Medical Necessity Manual for Behavioral Health
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Introduction
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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
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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
©1998-2012 The Mihalik Group Page 5
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
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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
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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
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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
©1998-2012 The Mihalik Group Page 9
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]
Medical Necessity Manual for Behavioral Health
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©1998-2012 The Mihalik Group Page 10
SERVICE SETTING CRITERIA
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Service Setting Criteria
©1998-2012 The Mihalik Group Page 11
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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Service Setting Criteria
©1998-2012 The Mihalik Group Page 12
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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Service Setting Criteria
©1998-2012 The Mihalik Group Page 13
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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Service Setting Criteria
©1998-2012 The Mihalik Group Page 14
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.
Behavioral Health Personnel
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
at any intensity, up to and including one-to-one observation.
AS.6. Facilities are available for the appropriate and safe use of restraints and seclusion, as
necessary, while maintaining individual dignity.
Behavioral Health Treatment Intensity
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.
Behavioral Health Diagnostic and Therapeutic Modalities
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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Service Setting Criteria
©1998-2012 The Mihalik Group Page 15
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
health history and mental status evaluation on each individual within twenty-four
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
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.
AS.15. Multiple therapeutic modalities are provided including individual psychotherapy,
medication management, couples therapy, group psychotherapy, psycho-educational
groups and family therapy.
AS.16. 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.
AS.17. Individualized unstructured therapeutic activities can be provided in addition to
structured therapeutic activities to meet the individual’s specific clinical needs.
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
participate in therapeutic activities.
Medical Services
AS.20. 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.
AS.21. 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.
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.
Behavioral Health Personnel
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
provision of treatment.
Individual Safety
OB.4. Appropriately trained and currently competent staff provide supervision of patients
at any intensity, up to and including one-to-one observation.
OB.5. Facilities are available for the appropriate and safe use of restraints and seclusion, as
necessary, while maintaining individual dignity.
Behavioral Health Treatment Intensity
OB.6. The program operates twenty-four hours per day, seven days per week.
Behavioral Health Diagnostic and Therapeutic Modalities
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
participate in therapeutic activities.
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Medical Services
OB.12. 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.
OB.13. 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.
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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Service Setting Criteria
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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.
Behavioral Health Personnel
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
provision of treatment.
Individual Safety
SM.6. Appropriately trained and currently competent staff provide supervision of patients
at any intensity, up to and including one-to-one observation.
Behavioral Health Treatment Intensity
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.
Behavioral Health Diagnostic and Therapeutic Modalities
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
and mental status evaluation be completed on each individual prior to initiation of
treatment.
SM.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.
SM.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.
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
structured therapeutic activities to meet the individual’s specific clinical needs.
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
participate in therapeutic activities.
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.
Behavioral Health Personnel
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
meet the individual’s clinical needs.
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
appropriately trained and currently competent behavioral health staff under the
direct supervision of behavioral health practitioners licensed, certified, or registered
to practice independently.
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
at any intensity, up to and including one-to-one observation.
Behavioral Health Treatment Intensity
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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Behavioral Health Diagnostic and Therapeutic Modalities
SS.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.
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
health history and mental status evaluation on each individual within twenty-four
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.
SS.14. 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.
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
necessitated initiation of treatment.
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
structured therapeutic activities to meet the individual’s specific clinical needs.
Supportive Services
SS.18. A moderate degree of support for activities of daily living can be provided if
clinically necessary.
SS.19. Staff are available to prompt, assist, or direct individuals, as appropriate, to
participate in therapeutic activities.
Medical Services
SS.20. 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.
SS.21. 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.
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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
medical services up to and including hospitalization.
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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.
Behavioral Health Personnel
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
provision of treatment.
Individual Safety
RM.4. A minimal to moderate degree of safety can be assured based on the degree of staff
supervision.
Behavioral Health Treatment Intensity
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.
Behavioral Health Diagnostic and Therapeutic Modalities
RM.8. 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
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Service Setting Criteria
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interview, observation, pencil and paper instruments, and basic pathologic and
laboratory analysis.
RM.9. 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.
RM.10. 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.
RM.11. 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.
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
necessitated initiation of treatment.
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
structured therapeutic activities to meet the individual’s specific clinical needs.
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
clinically necessary.
RM.17. Staff are available to prompt, assist, or direct individuals, as appropriate, to
participate in therapeutic activities.
Medical Services
RM.18. 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.
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
medical services up to and including hospitalization.
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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.
Behavioral Health Personnel
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.
Behavioral Health Treatment Intensity
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.
Behavioral Health Diagnostic and Therapeutic Modalities
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
necessitated initiation of treatment.
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
clinically necessary.
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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.
Behavioral Health Personnel
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.
Behavioral Health Treatment Intensity
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.
Behavioral Health Diagnostic and Therapeutic Modalities
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
necessitated initiation of treatment.
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
clinically necessary.
CR.13. Staff are available to prompt, assist, or direct individuals, as appropriate, to
participate in therapeutic activities.
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.
Behavioral Health Personnel
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
appropriately trained and currently competent behavioral health staff under the
direct supervision of behavioral health professionals licensed, certified, or registered
to practice independently.
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.
Behavioral Health Treatment Intensity
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.
Behavioral Health Diagnostic and Therapeutic Modalities
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
laboratory analysis.
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
and mental status evaluation be completed on each individual prior to initiation of
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,
medication management, couples therapy, group psychotherapy, psycho-educational
groups and family therapy.
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
necessitated initiation of treatment.
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
structured therapeutic activities to meet the individual’s specific clinical needs.
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
participate in therapeutic activities.
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.
Behavioral Health Personnel
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
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.
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.
Behavioral Health Treatment Intensity
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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Behavioral Health Diagnostic and Therapeutic Modalities
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
laboratory analysis.
PS.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.
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
behavioral health history and mental status evaluation completed prior to initiation
of treatment.
PS.14. Multiple therapeutic modalities are provided including individual psychotherapy,
medication management, couples therapy, group psychotherapy, psycho-educational
groups and family therapy.
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
necessitated initiation of treatment.
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
structured therapeutic activities to meet the individual’s specific clinical needs.
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
participate in therapeutic activities.
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.
Behavioral Health Personnel
IM.1. Psychiatrists are available as needed to provide consultation.
IM.2. Treatment is provided by an appropriate multidisciplinary team of 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.
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.
Behavioral Health Treatment Intensity
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.
Behavioral Health Diagnostic and Therapeutic Modalities
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
necessitated initiation of treatment.
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
structured therapeutic activities to meet the individual’s specific clinical needs.
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.
Behavioral Health Personnel
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
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.
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.
Behavioral Health Treatment Intensity
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.
Behavioral Health Diagnostic and Therapeutic Modalities
IS.8. Diagnostic modalities may be limited in scope to those that can be performed by
interview, observation, and pencil and paper instruments.
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
necessitated initiation of treatment.
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
structured therapeutic activities to meet the individual’s specific clinical needs.
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.
Behavioral Health Personnel
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.
Behavioral Health Treatment Intensity
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.
Behavioral Health Diagnostic and Therapeutic Modalities
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.
Behavioral Health Personnel
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
face-to-face with a behavioral health professional.
Behavioral Health Treatment Intensity
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.
Behavioral Health Diagnostic and Therapeutic Modalities
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).
Behavioral Health Personnel
HH.1. Treatment is provided by one or more behavioral health professionals licensed,
certified, or registered to practice independently who may be assisted by
appropriately trained and currently competent behavioral health staff under the
direct supervision of behavioral health professionals licensed, certified, or registered
to practice independently.
Individual Safety
HH.2. There is minimal assurance of individual safety other than when the individual is
face-to-face with a behavioral health professional.
Behavioral Health Treatment Intensity
HH.3. The intensity and duration of treatment are driven by individual need.
Behavioral Health Diagnostic and Therapeutic Modalities
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
interview, observation, pencil and paper instruments, and basic pathologic and
laboratory analysis.
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
participate in therapeutic activities.
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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.
Behavioral Health Personnel
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.
Behavioral Health Treatment Intensity
OM.3. Typically, one service per day is provided though the intensity and duration of
treatment is driven by individual need.
Behavioral Health Diagnostic and Therapeutic Modalities
OM.4. Diagnostic modalities are limited in scope to those that can be performed by
interview, observation, and pencil and paper instruments.
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
necessitated initiation of treatment.
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.
Behavioral Health Personnel
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.
Behavioral Health Treatment Intensity
OS.3. Typically one service per day is provided though the intensity and duration of
treatment is driven by individual need.
Behavioral Health Diagnostic and Therapeutic Modalities
OS.4. Diagnostic modalities are limited in scope to those that can be performed by
interview, observation, and pencil and paper instruments.
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
necessitated initiation of treatment.
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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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
initiation of treatment.
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
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
AS.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
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
treatment, the individual is diagnosed as having, or there is strong presumptive
evidence that the individual has a diagnosis of, a substance dependence 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.
AS.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.
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
supervision by trained personnel, and the availability of immediate medical care are
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.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
AS.A.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
the individual’s treatment.
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23-HOUR INPATIENT OBSERVATION
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
OB.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
OB.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
treatment, the individual is diagnosed as having, or there is strong presumptive
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
condition is primarily responsible for the symptoms or behaviors necessitating
treatment in this setting.
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
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
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
supervision by trained personnel, and the availability of immediate medical care are
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
the probability that the individual will become acutely seriously
medically compromised during the detoxification.
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
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
SM.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
SM.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.
SM.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.
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
resulting in impending, serious self-harm.
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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
therapeutic benefit, there is a clinically credible rationale for why those same
services could be effective now.
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.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
SM.A.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
SM.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:
SM.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
initiation of treatment.
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
describing the therapeutic interventions rendered and the individual’s response.
SM.A.c.6. As appropriate, members of the individual’s social support system are involved in
the individual’s treatment.
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SUB-ACUTE INPATIENT (RESIDENTIAL) TREATMENT: SUBSTANCE RELATED
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
SS.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
SS.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
treatment, the individual is diagnosed as having, or there is strong presumptive
evidence that the individual has a diagnosis of, a substance dependence 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.
SS.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.
SS.A.i.3. 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.
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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
substances requiring a medical detoxification (see Substance Use Requiring Medical
Detoxification on page 167).
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.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
SS.A.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
SS.A.c.2. There is an individualized plan of active, professionally directed treatment that
specifies goals, interventions, time frames, and anticipated outcomes appropriate to:
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
meaningful way of the symptoms of, or impairment in functioning
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
addiction medicine and other appropriate staff describing the therapeutic
interventions rendered and the individual’s response.
SS.A.c.6. As appropriate, members of the individual’s social support system are involved in
the individual’s treatment.
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RESPITE INPATIENT CARE: MENTAL HEALTH
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
RM.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
RM.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.
RM.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.
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
therapeutic benefit, there is a clinically credible rationale for why those same
services could be effective now.
RM.A.i.8. The place of service meets the Service Setting Criteria for Respite Inpatient: Mental
Health as described on page 23.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
RM.A.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
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
describing the therapeutic interventions rendered and the individual’s response.
RM.A.c.6. As appropriate, members of the individual’s social support system are involved in
the individual’s treatment.
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SUPERVISED COMMUNITY RESIDENTIAL CARE/GROUP HOME
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
CR.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
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
condition is primarily responsible for the symptoms or behaviors necessitating
treatment in this setting.
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
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.
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
assistance from staff or other professionals as needed within the structure of the
supervised residence.
CR.A.i.7. 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.
CR.A.i.8. The place of service meets the Service Setting Criteria for Supervised Community
Residential Care as described on page 27.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
CR.A.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
CR.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 that necessitated initiation of treatment.
CR.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 treatment
at this level.
CR.A.c.4. Habilitation or rehabilitation services are being rendered in a timely and
appropriately progressive manner.
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
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
PM.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
PM.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.
PM.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.
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
therapeutic benefit, there is a clinically credible rationale for why those same
services could be effective now.
PM.A.i.6. The place of service meets the Service Setting Criteria for Partial Hospital
Treatment: Mental Health as described on page 29.
One of the following Treatment Initiation Criteria is also required.
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.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
PM.A.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
PM.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:
PM.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
initiation of treatment.
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
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: SUBSTANCE RELATED
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
PS.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
PS.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
treatment, the individual is diagnosed as having, or there is strong presumptive
evidence that the individual has a diagnosis of, a substance dependence 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.
PS.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.
PS.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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PS.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.
PS.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.
PS.A.i.6. The place of service meets the Service Setting Criteria for Partial Hospital
Treatment: Substance Related as described on page 31.
One of the following Treatment Initiation Criteria is also required.
PS.A.i.7. 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) 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.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
PS.A.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
PS.A.c.2. There is an individualized plan of active, professionally directed treatment that
specifies goals, interventions, time frames, and anticipated outcomes appropriate to:
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
meaningful way of the symptoms of, or impairment in functioning
resulting from, the substance use disorder that necessitated initiation
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
professional and non professional staff, and periodic notes by the treating
psychiatrist or physician qualified in addiction medicine, describing the therapeutic
interventions rendered and the individual’s response.
PS.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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Adult Level of Care Criteria
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INTENSIVE OUTPATIENT TREATMENT: MENTAL HEALTH
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
IM.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
IM.A.i.1. Based on a behavioral health 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
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.
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
seeking professional help when not in a structured treatment setting.
IM.A.i.4. 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.
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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.
One of the following Treatment Initiation Criteria is also required.
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.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
IM.A.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
IM.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:
IM.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
initiation of treatment.
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
the individual’s treatment or appropriate efforts are made to enhance or develop the
individual’s social support system.
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INTENSIVE OUTPATIENT TREATMENT: SUBSTANCE RELATED
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
IS.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
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
seeking professional help when not in a structured treatment setting.
IS.A.i.4. 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.
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IS.A.i.5. The place of service meets the Service Setting Criteria for Intensive Outpatient:
Substance Related as described on page 35.
One of the following Treatment Initiation Criteria is also required.
IS.A.i.6. 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) 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.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
IS.A.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
IS.A.c.2. There is an individualized plan of active, professionally directed treatment that
specifies goals, interventions, time frames, and anticipated outcomes appropriate to:
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
meaningful way of the symptoms of, or impairment in functioning
resulting from, the substance use disorder or condition that
necessitated initiation of treatment.
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
professional and non-professional staff describing the therapeutic interventions
rendered and the individual’s response.
IS.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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OUTPATIENT CRISIS INTERVENTION
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
CI.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
CI.A.i.1. Based on a behavioral health history and mental status evaluation completed by a
behavioral health professional licensed, certified, or registered to practice
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
likely to respond to, professional therapeutic intervention.
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
therapeutic benefit, there is a clinically credible rationale for why those same
services could be effective now.
CI.A.i.7. The place of service meets the Service Setting Criteria for Outpatient Crisis
Intervention as described on page 37.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
CI.A.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
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
necessitated initiation of treatment.
CI.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.
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
describing the therapeutic interventions rendered and the individual’s response.
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
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
MT.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
MT.A.i.1. Based on a behavioral health history and mental status evaluation completed by a
behavioral health professional licensed, certified, or registered to practice
independently prior to, or at the time of, the mobile team’s visit 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.
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
therapeutic benefit, there is a clinically credible rationale for why those same
services could be effective now.
MT.A.i.8. The service being provided meets the Service Setting Criteria for Mobile Team as
described on page 39.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
MT.A.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
MT.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 or
condition that necessitated initiation of treatment.
MT.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.
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
describing the therapeutic interventions rendered and the individual’s response.
MT.A.c.7. As appropriate, members of the individual’s social support system are involved in
the individual’s treatment.
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HOME HEALTH SERVICES
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
HH.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
HH.A.i.1. Based on a behavioral health history and mental status evaluation completed by a
behavioral health professional licensed, certified, or registered to practice
independently prior to the home health visit, 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.
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,
occupational, scholastic or role functioning.
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
therapeutic benefit, there is a clinically credible rationale for why those same
services could be effective now.
HH.A.i.7. The service being provided meets the Service Setting Criteria for Home Health
Services as described on page 40.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
HH.A.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
HH.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 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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
describing the therapeutic interventions rendered and the individual’s response.
HH.A.c.6. As appropriate, members of the individual’s social support system are involved in
the individual’s treatment.
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TRADITIONAL OUTPATIENT TREATMENT: MENTAL HEALTH
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
OM.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
OM.A.i.1. Based on a behavioral health 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
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.
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
therapeutic benefit, there is a clinically credible rationale for why those same
services could be effective now.
OM.A.i.6. The place of service meets the Service Setting Criteria for Traditional Outpatient:
Mental Health as described on page 42.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
OM.A.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
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
version of the Diagnostic and Statistical Manual of Mental Disorders
for which maintenance treatment is required to maintain relief of
symptoms or level of functioning.
OM.A.c.3. There is an individualized plan of active, professionally directed treatment that
specifies the goals, interventions, time frames, and anticipated outcomes appropriate
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.
OM.A.c.4. 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.
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
describing the therapeutic interventions rendered and the individual’s response.
OM.A.c.7. 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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TRADITIONAL OUTPATIENT TREATMENT: SUBSTANCE RELATED
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
OS.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
OS.A.i.1. Based on a behavioral health 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.
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
social, occupational, scholastic or role functioning. (Transient,
expected reactions to psychosocial stressors are not sufficient to meet
this criterion.)
OR
OS.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.
OS.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.
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
therapeutic benefit, there is a clinically credible rationale for why those same
services could be effective now.
OS.A.i.6. The place of service meets the Service Setting Criteria for Traditional Outpatient:
Substance Related as described on page 43.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
OS.A.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
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
version of the Diagnostic and Statistical Manual of Mental Disorders
for which maintenance treatment is required to maintain relief of
symptoms or level of functioning.
OS.A.c.3. There is an individualized plan of active, professionally directed treatment that
specifies the goals, interventions, time frames, and anticipated outcomes appropriate
to improve or prevent deterioration or delay progression in a clinically meaningful
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
describing the therapeutic interventions rendered and the individual’s response.
OS.A.c.7. 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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CHILD AND ADOLESCENT
LEVEL OF CARE CRITERIA
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ACUTE INPATIENT TREATMENT: MENTAL HEALTH
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
AM.C.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.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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
AM.C.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.C.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.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
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.C.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.C.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 possibly contain the individual because:
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
medically dangerous side effects from prescribed psychotropic
medications.
OR
AM.C.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.C.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.C.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.C.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
AM.C.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.C.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
initiation of treatment.
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
describing the therapeutic interventions rendered and the individual’s response.
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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Licensed to LifeSynch under agreement with The Mihalik Group
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ACUTE INPATIENT TREATMENT: SUBSTANCE RELATED
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
AS.C.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
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
professional licensed, certified, or registered to practice independently and reviewed
by a psychiatrist or physician qualified in addiction medicine 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 dependence 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.
AS.C.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.
AS.C.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.C.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 or detoxify the individual because:
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
the probability that the individual will become acutely seriously
medically compromised during the detoxification.
AS.C.i.5. The place of service meets the Service Setting Criteria for Acute Inpatient:
Substance Related as described on page 14.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
AS.C.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
AS.C.c.2. There is an individualized plan of active, professionally directed treatment that
specifies goals, interventions, time frames, and anticipated outcomes appropriate to:
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
addiction medicine and other appropriate staff describing the therapeutic
interventions rendered and the individual’s response.
AS.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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23-HOUR INPATIENT OBSERVATION
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
OB.C.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
OB.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
professional licensed, certified, or registered to practice independently and reviewed
by a psychiatrist or physician qualified in addiction medicine 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 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.C.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.
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
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
OB.C.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.C.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 possibly contain the individual because:
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
that the individual will experience, unusually severe side effects from
prescribed psychotropic medications.
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
basis resulting from dependence on a class or classes and quantity or
quantities of substances requiring a medical detoxification.
OR
OB.C.i.4.5 The individual has a medical co-morbidity that significantly increases
the probability that the individual will become acutely seriously
medically compromised during the detoxification.
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
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
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
SM.C.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
SM.C.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.
SM.C.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.
SM.C.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
resulting in impending, serious self-harm.
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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
absence of sub-acute inpatient (residential) treatment.
SM.C.i.6. 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.
SM.C.i.7. The place of service meets the Service Setting Criteria for Sub-Acute Inpatient
(Residential): Mental Health as described on page 18.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
SM.C.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
SM.C.c.2. There is an individualized plan of active, professionally directed treatment that
specifies the goals, interventions, time frames, and anticipated outcomes appropriate
to:
SM.C.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
initiation of treatment.
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
describing the therapeutic interventions rendered and the individual’s response.
SM.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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Licensed to LifeSynch under agreement with The Mihalik Group
Child and Adolescent Level of Care Criteria
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SUB-ACUTE INPATIENT (RESIDENTIAL) TREATMENT: SUBSTANCE RELATED
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
SS.C.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
SS.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
professional licensed, certified, or registered to practice independently and reviewed
by a psychiatrist or physician qualified in addiction medicine 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 dependence 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.
SS.C.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.
SS.C.i.3. 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.
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SS.C.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.C.i.5. 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) 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
complications if substance use resumes and the individual is not capable of
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,
occupational, scholastic or role functioning.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
SS.C.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
SS.C.c.2. There is an individualized plan of active, professionally directed treatment that
specifies goals, interventions, time frames, and anticipated outcomes appropriate to:
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
meaningful way of the symptoms of, or impairment in functioning
resulting from, the substance use disorder that necessitated initiation
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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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
addiction medicine and other appropriate staff describing the therapeutic
interventions rendered and the individual’s response.
SS.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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SUPERVISED COMMUNITY RESIDENTIAL CARE/GROUP HOME
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
CR.C.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
CR.C.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.C.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.
CR.C.i.3. As a result of the mental disorder, the individual’s social functioning has become
impaired to the extent that:
CR.C.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.C.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.C.i.4. Supervised residential 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.
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
supervised residence.
CR.C.i.7. 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.
CR.C.i.8. The place of service meets the Service Setting Criteria for Supervised Community
Residential Care as described on page 27.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
CR.C.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
CR.C.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 or delay progression in a clinically meaningful way of the
impairment in functioning resulting from the mental disorder that necessitated
initiation of treatment.
CR.C.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 treatment
at this level.
CR.C.c.4. Habilitation or rehabilitation services are being rendered in a timely and
appropriately progressive manner.
CR.C.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.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
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
TF.C.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
TF.C.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.
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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Licensed to LifeSynch under agreement with The Mihalik Group
Child and Adolescent Level of Care Criteria
©1998-2012 The Mihalik Group Page 97
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
therapeutic benefit, there is a clinically credible rationale for why those same
services could be effective now.
TF.C.i.7. The place of service meets the Service Setting Criteria for Therapeutic Foster Care
as described on page 23.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
TF.C.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
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
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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Version 7.0.1
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Licensed to LifeSynch under agreement with The Mihalik Group
Child and Adolescent Level of Care Criteria
©1998-2012 The Mihalik Group Page 98
PARTIAL HOSPITAL TREATMENT: MENTAL HEALTH
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
PM.C.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
PM.C.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.
PM.C.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.
PM.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 without the addition of an intensive multi-modal, multi-disciplinary
treatment program that includes medical and/or nursing care.
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Licensed to LifeSynch under agreement with The Mihalik Group
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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
therapeutic benefit, there is a clinically credible rationale for why those same
services could be effective now.
PM.C.i.6. The place of service meets the Service Setting Criteria for Partial Hospital
Treatment: Mental Health as described on page 29.
One of the following Treatment Initiation Criteria is also required.
PM.C.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.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
traditional or intensive outpatient treatment in the past three months.
OR
PM.C.i.8.3 It is clinically probable that the individual will require treatment at a
higher level of care if services are not provided at this level.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
PM.C.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
PM.C.c.2. There is an individualized plan of active, professionally directed treatment that
specifies the goals, interventions, time frames, and anticipated outcomes appropriate
to:
PM.C.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
initiation of treatment.
AND
PM.C.c.2.2 Address a co-morbid substance use disorder or condition, if one
exists.
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Licensed to LifeSynch under agreement with The Mihalik Group
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PM.C.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.
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
professional and non professional staff, and periodic notes by the treating
psychiatrist, describing the therapeutic interventions rendered and the individual’s
response.
PM.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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Version 7.0.1
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Licensed to LifeSynch under agreement with The Mihalik Group
Child and Adolescent Level of Care Criteria
©1998-2012 The Mihalik Group Page 101
PARTIAL HOSPITAL TREATMENT: SUBSTANCE RELATED
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
PS.C.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
PS.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
professional licensed, certified, or registered to practice independently and reviewed
by a psychiatrist or physician qualified in addiction medicine 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 dependence 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.
PS.C.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.
PS.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 without the addition of an intensive multi-modal, multi-disciplinary
treatment program that includes medical and/or nursing care.
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Licensed to LifeSynch under agreement with The Mihalik Group
Child and Adolescent Level of Care Criteria
©1998-2012 The Mihalik Group Page 102
PS.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.
PS.C.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.
PS.C.i.6. The place of service meets the Service Setting Criteria for Partial Hospital
Treatment: Substance Related as described on page 31.
One of the following Treatment Initiation Criteria is also required.
PS.C.i.7. 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) and is capable of controlling behaviors and/or seeking
professional help when not in a structured treatment setting.
PS.C.i.8. The individual has participated in and failed a substantial course of traditional or
intensive outpatient treatment in the past three months.
PS.C.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.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
PS.C.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
PS.C.c.2. There is an individualized plan of active, professionally directed treatment that
specifies goals, interventions, time frames, and anticipated outcomes appropriate to:
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
meaningful way of the symptoms of, or impairment in functioning
resulting from, the substance use disorder that necessitated initiation
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
PS.C.c.4. Treatment is being rendered in a timely and appropriately progressive manner.
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Licensed to LifeSynch under agreement with The Mihalik Group
Child and Adolescent Level of Care Criteria
©1998-2012 The Mihalik Group Page 103
PS.C.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 or physician qualified in addiction medicine, describing the therapeutic
interventions rendered and the individual’s response.
PS.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.
Medical Necessity Manual for Behavioral Health
Version 7.0.1
September 1, 2012
Licensed to LifeSynch under agreement with The Mihalik Group
Child and Adolescent Level of Care Criteria
©1998-2012 The Mihalik Group Page 104
INTENSIVE OUTPATIENT TREATMENT: MENTAL HEALTH
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
IM.C.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
IM.C.i.1. Based on a behavioral health 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
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.
IM.C.i.2. The individual’s internal resources, home environment, family resources, and
support network are inadequate to provide the structure and support needed by the
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
behaviors, and seeking assistance from appropriate members of the individual’s
social support system when not in a structured treatment setting.
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Licensed to LifeSynch under agreement with The Mihalik Group
Child and Adolescent Level of Care Criteria
©1998-2012 The Mihalik Group Page 105
IM.C.i.4. 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.
IM.C.i.5. The place of service meets the Service Setting Criteria for Intensive Outpatient:
Mental Health as described on page 33.
One of the following Treatment Initiation Criteria is also required.
IM.C.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.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
individual’s level of functioning would decline necessitating treatment at a higher
level of care.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
IM.C.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
IM.C.c.2. There is an individualized plan of active, professionally directed treatment that
specifies the goals, interventions, time frames, and anticipated outcomes appropriate
to:
IM.C.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
initiation of treatment.
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
professional and non-professional staff describing the therapeutic interventions
rendered and the individual’s response.
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Licensed to LifeSynch under agreement with The Mihalik Group
Child and Adolescent Level of Care Criteria
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IM.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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Version 7.0.1
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Licensed to LifeSynch under agreement with The Mihalik Group
Child and Adolescent Level of Care Criteria
©1998-2012 The Mihalik Group Page 107
INTENSIVE OUTPATIENT TREATMENT: SUBSTANCE RELATED
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
IS.C.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
IS.C.i.1. Based on a behavioral health 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.C.i.2. The individual’s internal resources, home environment, family resources, and
support network are inadequate to provide the structure and support needed by the
individual without the addition of an intensive treatment program.
IS.C.i.3. 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.
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Licensed to LifeSynch under agreement with The Mihalik Group
Child and Adolescent Level of Care Criteria
©1998-2012 The Mihalik Group Page 108
IS.C.i.4. 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.
IS.C.i.5. The place of service meets the Service Setting Criteria for Intensive Outpatient:
Substance Related as described on page 35.
One of the following Treatment Initiation Criteria is also required.
IS.C.i.6. 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) and the individual is capable of controlling behaviors
and/or seeking professional help when not in a structured treatment setting.
IS.C.i.7. The individual has participated in and failed a substantial course of traditional
outpatient treatment in the past three months.
IS.C.i.8. 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.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
IS.C.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
IS.C.c.2. There is an individualized plan of active, professionally directed treatment that
specifies goals, interventions, time frames, and anticipated outcomes appropriate to:
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
meaningful way of the symptoms of, or impairment in functioning
resulting from, the substance use disorder or condition that
necessitated initiation of treatment.
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
interventions rendered and the individual’s response.
IS.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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Version 7.0.1
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Licensed to LifeSynch under agreement with The Mihalik Group
Child and Adolescent Level of Care Criteria
©1998-2012 The Mihalik Group Page 110
OUTPATIENT CRISIS INTERVENTION
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
CI.C.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
CI.C.i.1. Based on a behavioral health history and mental status evaluation completed by a
behavioral health professional licensed, certified, or registered to practice
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
likely to respond to, professional therapeutic intervention.
CI.C.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.C.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.C.i.4. The individual’s internal resources, home environment, family resources, and
support network are inadequate to provide the structure and support needed by the
individual without the addition of intensive treatment.
CI.C.i.5. 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.
CI.C.i.6. 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.
CI.C.i.7. The place of service meets the Service Setting Criteria for Outpatient Crisis
Intervention as described on page 37.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
CI.C.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
CI.C.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 or
condition that necessitated initiation of treatment.
CI.C.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.
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
describing the therapeutic interventions rendered and the individual’s response.
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
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
MT.C.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
MT.C.i.1. Based on a behavioral health history and mental status evaluation completed by a
behavioral health professional licensed, certified, or registered to practice
independently prior to, or at the time of the mobile team’s visit, 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.
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
mobile team services.
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MT.C.i.5. The individual’s internal resources, home environment, family resources, and
support network are inadequate to provide the structure and support needed by the
individual without mobile team treatment.
MT.C.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.C.i.7. 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.
MT.C.i.8. The service being provided meets the Service Setting Criteria for Mobile Team as
described on page 39.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
MT.C.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
MT.C.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 or
condition that necessitated initiation of treatment.
MT.C.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.
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
describing the therapeutic interventions rendered and the individual’s response.
MT.C.c.7. 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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HOME HEALTH SERVICES
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
HH.C.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
HH.C.i.1. Based on a behavioral health history and mental status evaluation completed by a
behavioral health professional licensed, certified, or registered to practice
independently prior to the home health visit, the individual is diagnosed as having,
or there is strong presumptive evidence that the individual has a diagnosis of, a
mental disorder according or condition 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.
HH.C.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,
occupational, scholastic or role functioning.
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
effectiveness and efficiency of the clinical intervention.
HH.C.i.4. The individual’s internal resources, home environment, family resources, and
support network are inadequate to provide the structure and support needed by the
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
in ability to provide for basic self-care needs can be improved or stabilized by
therapeutic intervention at this level.
HH.C.i.6. 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.
HH.C.i.7. The service being provided meets the Service Setting Criteria for Home Health
Services as described on page 40.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
HH.C.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
HH.C.c.2. There is an individualized plan of active, professionally directed treatment that
specifies the goals, interventions, time frames, and anticipated outcomes appropriate
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.C.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.
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
describing the therapeutic interventions rendered and the individual’s response.
HH.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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TRADITIONAL OUTPATIENT TREATMENT: MENTAL HEALTH
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
OM.C.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
OM.C.i.1. Based on a behavioral health 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
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.
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
social, occupational, scholastic or role functioning. (Transient,
expected reactions to psychosocial stressors are not sufficient to meet
this criterion.)
OR
OM.C.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.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
behaviors, and seeking assistance from appropriate members of the individual’s
social support system when not in a treatment setting.
OM.C.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.
OM.C.i.6. The place of service meets the Service Setting Criteria for Traditional Outpatient:
Mental Health as described on page 42.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
OM.C.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
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
version of the Diagnostic and Statistical Manual of Mental Disorders
for which maintenance treatment is required to maintain relief of
symptoms or level of functioning.
OM.C.c.3. There is an individualized plan of active, professionally directed treatment that
specifies the goals, interventions, time frames, and anticipated outcomes appropriate
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.
OM.C.c.4. 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.
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
describing the therapeutic interventions rendered and the individual’s response.
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OM.C.c.7. 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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TRADITIONAL OUTPATIENT TREATMENT: SUBSTANCE RELATED
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
OS.C.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
OS.C.i.1. Based on a behavioral health 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.
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
social, occupational, scholastic or role functioning. (Transient,
expected reactions to psychosocial stressors are not sufficient to meet
this criterion.)
OR
OS.C.i.1.1 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.
OS.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.
OS.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 treatment setting.
OS.C.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.
OS.C.i.6. The place of service meets the Service Setting Criteria for Traditional Outpatient:
Substance Related as described on page 43.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
OS.C.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
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
version of the Diagnostic and Statistical Manual of Mental Disorders
for which maintenance treatment is required to maintain relief of
symptoms or level of functioning.
OS.C.c.3. There is an individualized plan of active, professionally directed treatment that
specifies the goals, interventions, time frames, and anticipated outcomes appropriate
to improve or prevent deterioration or delay progression in a clinically meaningful
way of the symptoms of, or impairment in functioning resulting from, the substance
use disorder or condition that necessitated initiation of treatment.
OS.C.c.4. 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.
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
describing the therapeutic interventions rendered and the individual’s response.
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OS.C.c.7. 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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GERIATRIC
LEVEL OF CARE CRITERIA
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ACUTE INPATIENT TREATMENT: MENTAL HEALTH
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
AM.G.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.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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
AM.G.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.G.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.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
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.G.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.G.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 possibly contain the individual because:
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
medically dangerous side effects from prescribed psychotropic
medications.
OR
AM.G.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.G.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.G.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.G.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
AM.G.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.G.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
initiation of treatment.
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
describing the therapeutic interventions rendered and the individual’s response.
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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ACUTE INPATIENT TREATMENT: SUBSTANCE RELATED
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
AS.G.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
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
professional licensed, certified, or registered to practice independently and reviewed
by a psychiatrist or physician qualified in addiction medicine 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 dependence 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.
AS.G.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.
AS.G.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.G.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 or detoxify the individual because:
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
the probability that the individual will become acutely seriously
medically compromised during the detoxification.
AS.G.i.5. The place of service meets the Service Setting Criteria for Acute Inpatient:
Substance Related as described on page 14.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
AS.G.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
AS.G.c.2. There is an individualized plan of active, professionally directed treatment that
specifies goals, interventions, time frames, and anticipated outcomes appropriate to:
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
addiction medicine and other appropriate staff describing the therapeutic
interventions rendered and the individual’s response.
AS.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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23-HOUR INPATIENT OBSERVATION
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
OB.G.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
OB.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
professional licensed, certified, or registered to practice independently and reviewed
by a psychiatrist or physician qualified in addiction medicine 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 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.G.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.
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
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
OB.G.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.G.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 possibly contain the individual because:
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
that the individual will experience, unusually severe side effects from
prescribed psychotropic medications.
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
basis resulting from dependence on a class or classes and quantity or
quantities of substances requiring a medical detoxification.
OR
OB.G.i.4.5 The individual has a medical co-morbidity that significantly increases
the probability that the individual will become acutely seriously
medically compromised during the detoxification.
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
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
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
SM.G.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
SM.G.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.
SM.G.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.
SM.G.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
resulting in impending, serious self-harm.
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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
absence of sub-acute inpatient (residential) treatment.
SM.G.i.6. 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.
SM.G.i.7. The place of service meets the Service Setting Criteria for Sub-Acute Inpatient
(Residential): Mental Health as described on page 18.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
SM.G.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
SM.G.c.2. There is an individualized plan of active, professionally directed treatment that
specifies the goals, interventions, time frames, and anticipated outcomes appropriate
to:
SM.G.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
initiation of treatment.
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
the length of stay typically associated with treatment at this level.
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
describing the therapeutic interventions rendered and the individual’s response.
SM.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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Geriatric Level of Care Criteria
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SUB-ACUTE INPATIENT (RESIDENTIAL) TREATMENT: SUBSTANCE RELATED
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
SS.G.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
SS.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
professional licensed, certified, or registered to practice independently and reviewed
by a psychiatrist or physician qualified in addiction medicine 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 dependence 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.
SS.G.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.
SS.G.i.3. 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.
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SS.G.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.G.i.5. 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) 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
complications if substance use resumes and the individual is not capable of
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.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
SS.G.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
SS.G.c.2. There is an individualized plan of active, professionally directed treatment that
specifies goals, interventions, time frames, and anticipated outcomes appropriate to:
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
meaningful way of the symptoms of, or impairment in functioning
resulting from, the substance use disorder that necessitated initiation
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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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
addiction medicine and other appropriate staff describing the therapeutic
interventions rendered and the individual’s response.
SS.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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RESPITE INPATIENT CARE: MENTAL HEALTH
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
RM.G.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
RM.G.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.
RM.G.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.
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
assistance from staff or other professionals as needed within the structure of the
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
therapeutic benefit, there is a clinically credible rationale for why those same
services could be effective now.
RM.G.i.8. The place of service meets the Service Setting Criteria for Respite Inpatient: Mental
Health as described on page 23.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
RM.G.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
RM.G.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.G.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.G.c.4. Habilitation or rehabilitation services are being rendered in a timely and
appropriately progressive manner.
RM.G.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.
RM.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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SUPERVISED COMMUNITY RESIDENTIAL CARE/GROUP HOME
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
CR.G.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
CR.G.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.G.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.
CR.G.i.3. As a result of the mental disorder, the individual’s social functioning has become
impaired to the extent that:
CR.G.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.G.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.G.i.4. Supervised residential 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, 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
supervised residence.
CR.G.i.7. 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.
CR.G.i.8. The place of service meets the Service Setting Criteria for Supervised Community
Residential Care as described on page 27.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
CR.G.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
CR.G.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 or delay progression in a clinically meaningful way of the
impairment in functioning resulting from the mental disorder that necessitated
initiation of treatment.
CR.G.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 treatment
at this level.
CR.G.c.4. Habilitation or rehabilitation services are being rendered in a timely and
appropriately progressive manner.
CR.G.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.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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Geriatric Level of Care Criteria
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PARTIAL HOSPITAL TREATMENT: MENTAL HEALTH
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
PM.G.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
PM.G.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.
PM.G.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.
PM.G.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.G.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.G.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.
PM.G.i.6. The place of service meets the Service Setting Criteria for Partial Hospital
Treatment: Mental Health as described on page 29.
One of the following Treatment Initiation Criteria is also required.
PM.G.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.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
traditional or intensive outpatient treatment in the past three months.
OR
PM.G.i.8.3 It is clinically probable that the individual will require treatment at a
higher level of care if services are not provided at this level.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
PM.G.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
PM.G.c.2. There is an individualized plan of active, professionally directed treatment that
specifies the goals, interventions, time frames, and anticipated outcomes appropriate
to:
PM.G.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
initiation of treatment.
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
professional and non professional staff, and periodic notes by the treating
psychiatrist, describing the therapeutic interventions rendered and the individual’s
response.
PM.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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PARTIAL HOSPITAL TREATMENT: SUBSTANCE RELATED
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
PS.G.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
PS.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
professional licensed, certified, or registered to practice independently and reviewed
by a psychiatrist or physician qualified in addiction medicine 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 dependence 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.
PS.G.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.
PS.G.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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PS.G.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.
PS.G.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.
PS.G.i.6. The place of service meets the Service Setting Criteria for Partial Hospital
Treatment: Substance Related as described on page 31.
One of the following Treatment Initiation Criteria is also required.
PS.G.i.7. 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) and is capable of controlling behaviors and/or seeking
professional help when not in a structured treatment setting.
PS.G.i.8. The individual has participated in and failed a substantial course of traditional or
intensive outpatient treatment in the past three months.
PS.G.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.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
PS.G.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
PS.G.c.2. There is an individualized plan of active, professionally directed treatment that
specifies goals, interventions, time frames, and anticipated outcomes appropriate to:
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
meaningful way of the symptoms of, or impairment in functioning
resulting from, the substance use disorder that necessitated initiation
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
professional and non professional staff, and periodic notes by the treating
psychiatrist or physician qualified in addiction medicine, describing the therapeutic
interventions rendered and the individual’s response.
PS.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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INTENSIVE OUTPATIENT TREATMENT: MENTAL HEALTH
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
IM.G.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
IM.G.i.1. Based on a behavioral health 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
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.
IM.G.i.2. The individual’s internal resources, home environment, family resources, and
support network are inadequate to provide the structure and support needed by the
individual without the addition of an intensive treatment program.
IM.G.i.3. 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.
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IM.G.i.4. 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.
IM.G.i.5. The place of service meets the Service Setting Criteria for Intensive Outpatient:
Mental Health as described on page 33.
One of the following Treatment Initiation Criteria is also required.
IM.G.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.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.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
IM.G.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
IM.G.c.2. There is an individualized plan of active, professionally directed treatment that
specifies the goals, interventions, time frames, and anticipated outcomes appropriate
to:
IM.G.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
initiation of treatment.
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
professional and non-professional staff describing the therapeutic interventions
rendered and the individual’s response.
IM.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
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appropriate efforts are made to enhance or develop the individual’s social support
system.
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INTENSIVE OUTPATIENT TREATMENT: SUBSTANCE RELATED
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
IS.G.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
IS.G.i.1. Based on a behavioral health 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.G.i.2. The individual’s internal resources, home environment, family resources, and
support network are inadequate to provide the structure and support needed by the
individual without the addition of an intensive treatment program.
IS.G.i.3. 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.
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IS.G.i.4. 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.
IS.G.i.5. The place of service meets the Service Setting Criteria for Intensive Outpatient:
Substance Related as described on page 35.
One of the following Treatment Initiation Criteria is also required.
IS.G.i.6. 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) and the individual is capable of controlling behaviors
and/or seeking professional help when not in a structured treatment setting.
IS.G.i.7. The individual has participated in and failed a substantial course of traditional
outpatient treatment in the past three months.
IS.G.i.8. 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.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
IS.G.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
IS.G.c.2. There is an individualized plan of active, professionally directed treatment that
specifies goals, interventions, time frames, and anticipated outcomes appropriate to:
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
meaningful way of the symptoms of, or impairment in functioning
resulting from, the substance use disorder or condition that
necessitated initiation of treatment.
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
professional and non-professional staff describing the therapeutic interventions
rendered and the individual’s response.
IS.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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OUTPATIENT CRISIS INTERVENTION
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
CI.G.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
CI.G.i.1. Based on a behavioral health history and mental status evaluation completed by a
behavioral health professional licensed, certified, or registered to practice
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
likely to respond to, professional therapeutic intervention.
CI.G.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.G.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.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
behaviors, and seeking assistance from appropriate members of the individual’s
social support system.
CI.G.i.6. 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.
CI.G.i.7. The place of service meets the Service Setting Criteria for Outpatient Crisis
Intervention as described on page 37.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
CI.G.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
CI.G.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 or
condition that necessitated initiation of treatment.
CI.G.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.
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
describing the therapeutic interventions rendered and the individual’s response.
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
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
MT.G.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
MT.G.i.1. Based on a behavioral health history and mental status evaluation completed by a
behavioral health professional licensed, certified, or registered to practice
independently prior to, or at the time of the mobile team’s visit, 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.
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
mobile team services.
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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
deterioration in ability to provide for basic self-care needs can be adequately
managed.
MT.G.i.7. 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.
MT.G.i.8. The service being provided meets the Service Setting Criteria for Mobile Team as
described on page 39.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
MT.G.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
MT.G.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 or
condition that necessitated initiation of treatment.
MT.G.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.
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
describing the therapeutic interventions rendered and the individual’s response.
MT.G.c.7. 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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HOME HEALTH SERVICES
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
HH.G.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
HH.G.i.1. Based on a behavioral health history and mental status evaluation completed by a
behavioral health professional licensed, certified, or registered to practice
independently prior to the home health visit, the individual is diagnosed as having,
or there is strong presumptive evidence that the individual has a diagnosis of, a
mental disorder according or condition 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.
HH.G.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,
occupational, scholastic or role functioning.
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
effectiveness and efficiency of the clinical intervention.
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
in ability to provide for basic self-care needs can be improved or stabilized by
therapeutic intervention at this level.
HH.G.i.6. 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.
HH.G.i.7. The service being provided meets the Service Setting Criteria for Home Health
Services as described on page 40.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
HH.G.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
HH.G.c.2. There is an individualized plan of active, professionally directed treatment that
specifies the goals, interventions, time frames, and anticipated outcomes appropriate
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.G.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.
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
describing the therapeutic interventions rendered and the individual’s response.
HH.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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TRADITIONAL OUTPATIENT TREATMENT: MENTAL HEALTH
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
OM.G.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
OM.G.i.1. Based on a behavioral health 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
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.
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
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.G.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.G.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 treatment setting.
OM.G.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.
OM.G.i.6. The place of service meets the Service Setting Criteria for Traditional Outpatient:
Mental Health as described on page 42.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
OM.G.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
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
version of the Diagnostic and Statistical Manual of Mental Disorders
for which maintenance treatment is required to maintain relief of
symptoms or level of functioning.
OM.G.c.3. There is an individualized plan of active, professionally directed treatment that
specifies the goals, interventions, time frames, and anticipated outcomes appropriate
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.
OM.G.c.4. 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.
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
describing the therapeutic interventions rendered and the individual’s response.
OM.G.c.7. As appropriate, family members, caregivers, and/or other members of the
individual’s social support system are involved in the individual’s treatment or
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appropriate efforts are made to enhance or develop the individual’s social support
system.
OM.G.c.8. The individual demonstrates the ability to meaningfully recall therapeutic
discussions from session to session.
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TRADITIONAL OUTPATIENT TREATMENT: SUBSTANCE RELATED
General Criteria
All of the following General Criteria are required throughout the episode of care.
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
signs, symptoms, history, and diagnosis.
OS.G.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.
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,
incarceration, or other legal consequences.
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
OS.G.i.1. Based on a behavioral health 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.
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
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.
OS.G.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.
OS.G.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 treatment setting.
OS.G.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.
OS.G.i.6. The place of service meets the Service Setting Criteria for Traditional Outpatient:
Substance Related as described on page 43.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
OS.G.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
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
version of the Diagnostic and Statistical Manual of Mental Disorders
for which maintenance treatment is required to maintain relief of
symptoms or level of functioning.
OS.G.c.3. There is an individualized plan of active, professionally directed treatment that
specifies the goals, interventions, time frames, and anticipated outcomes appropriate
to improve or prevent deterioration or delay progression in a clinically meaningful
way of the symptoms of, or impairment in functioning resulting from, the substance
use disorder or condition that necessitated initiation of treatment.
OS.G.c.4. 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.
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
describing the therapeutic interventions rendered and the individual’s response.
OS.G.c.7. As appropriate, family members, caregivers, and/or other members of the
individual’s social support system are involved in the individual’s treatment or
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appropriate efforts are made to enhance or develop the individual’s social support
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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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).
Service Setting Criteria
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
All of the following General Criteria are required throughout the episode of care.
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
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.
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.
When applied to psychological and neuropsychological testing, this criterion is
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,
incarceration, or other legal consequences.
PT.g.7. The services are not predominantly domiciliary or custodial.
When applied to psychological and neuropsychological testing, this criterion is
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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Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
PT.i.1. Based on a behavioral health history and mental status evaluation completed by a
behavioral health professional licensed, certified, or registered to practice
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.
One of the following Treatment Initiation Criteria is also required.
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.
Treatment Initiation Criteria
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.
Treatment Initiation Criteria
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).
Treatment Continuation Criteria
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.
Treatment Initiation Criteria
All of the following Treatment Initiation Criteria are required.
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
behavioral health professional licensed, certified, or registered to practice
independently prior to initiation of treatment, the individual is diagnosed as having a
mental disorder or condition according to the most recent version of the Diagnostic
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
support network are adequate to provide the structure and support needed by the
individual.
AB.i.12. 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.
AB.i.13. The place of service meets the Service Setting Criteria for Traditional Outpatient:
Mental Health as described on page 42.
Treatment Continuation Criteria
All of the following Treatment Continuation Criteria are required throughout the episode of care.
AB.c.1. The individual continues to meet the treatment initiation criteria each day that
services are provided at this level.
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
plan, and criteria for discharge are clinically efficient, reasonable, and achievable in
the length of stay typically associated with treatment at this level.
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
describing the therapeutic interventions rendered and the individual’s response.
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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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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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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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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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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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
©1998-2012 The Mihalik Group Page 190
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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