Alliance Behavioral Healthcare Level of Care Guidelines for State Funded Adult Mental Health and Substance Abuse Services

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1 Alliance Behavioral Healthcare of Care Guidelines for State Funded Adult Mental Health and Substance Abuse s Mental Health (Effective 10/1/2012) The levels of care criteria provide a framework for the authorization of medically necessary services to adults with psychiatric diagnoses. This document will summarize the crosswalk between the and the Adult Mental Health s of Care Criteria for services which are authorized by the Alliance UM Department LEVEL 0 - BASIC SERVICES - Prevention and Health Maintenance Basic services are designed to prevent the onset of illness or to limit the magnitude of morbidity associated with already established disease processes. These services may be developed for individual or community application, and are generally carried out in a variety of community settings. These services will be available to all members of the community. (Not included in the benefit) LEVEL 1 - Recovery Maintenance and Health Management This level of care provides treatment to clients who are living either independently or with minimal support in the community, and who have achieved significant recovery from past episodes of illness. Treatment and service needs do not require supervision or frequent contact. LEVEL 2 - Low Intensity Community Based s This level of care provides treatment to clients who need ongoing treatment, but who are living either independently or with minimal support in the community. Treatment and service needs do not require intense supervision or very frequent contact. Programs of this type have traditionally been clinic-based programs LEVEL 3 - High Intensity Community Based s This level of care provides treatment to clients who need intensive support and treatment, but who are living either independently or with minimal support in the community. needs do not require daily supervision, but treatment needs require contact several times per week. Programs of this type have traditionally been clinic based programs. LEVEL 4 - Medically Monitored Non-Residential s This level of care refers to services provided to clients capable of living in the community either in supportive or independent settings, but whose treatment needs require intensive management by a multi disciplinary treatment team. s, which would be included in this level of care, have traditionally been described as partial hospital programs and as assertive community treatment programs. LEVEL 5 - Medically Monitored Residential s This level of care has traditionally been provided in non-hospital, free standing residential facilities based in the community to ameliorate a non-lethal psychiatric emergency in a facility-based crisis stabilization unit. In some cases, longer-term care for persons with a chronic, disability, which has traditionally been provided in nursing homes or similar facilities, may be included at this level. Substance Abuse The service definitions all contain entrance criteria and continued stay criteria that are based on specific Patient Placement Criteria. This document will summarize the crosswalk between Patient Placement Criteria and the Adult Substance Abuse s of Care Criteria for services which are authorized through the Alliance UM Department LEVEL Early intervention, prevention, or community support group services (Not included in the benefit) LEVEL 1 and 2 I Outpatient Treatment Consumers in this category may receive outpatient groups, individual and family therapy, medication management, psychological testing, Opioid Maintenance services or other services necessary to maintain the consumer in the community. LEVEL 3 II.I Intensive Outpatient s This level of care includes intensive frequency and duration of community-based treatment (9 or more hours) and support services and as such would be eligible for services in 1 as well as intensive outpatient services. LEVEL 4 II.5 Partial Hospitalization Consumers at this level are eligible for services in 1 and Two and also are eligible for Substance Abuse Comprehensive Outpatient Treatment or partial hospital care involving the highest frequency and duration of community-based treatment (20 or more hours) and support services. LEVEL 5 III Clinically Managed Low to Medium Intensity Residential Treatment This level includes services for 1 consumers who meet criteria for III and higher. Consumers at this level are eligible for services in A, B, C, as well as Non-medical Community Residential Detoxification or Rehabilitation s, SA Halfway House, Medically Monitored Residential Treatment.. LEVEL 6 III.7-IV Medically Monitored Intensive Inpatient Treatment to Medically Managed Intensive Inpatient Treatment such as Hospital-based detoxification or long-term facility-based rehabilitation. LEVEL 6 - Medically Managed Residential s six services are provided in psychiatric hospital settings or in medical hospital settings where mental health conditions result in injury to self or others.

2 Alliance Behavioral Healthcare IPRS Adult Mental Health and Substance Abuse s Benefit Plan Assertive Community Treatment Team (ACTT) Assertive Engagement - Clinical Assessment Community Support Team (CST) Crisis Evaluation & Observation H0040 YA H0031 H0001 H2015 YA324 6 months 4 units per PCP/PCP update Record month (Initial + Resupporting SPMI and/or Authorization) multiple hospitalizations/crisis Authorizations only, provider to have plan in PCP/PCP update MH: 32 units for 30 days. Annual maximum 32 units. 48 Units as part of Durham SA programs. 2 per year, 8 unit max for H code billing 128 units over sixty days, 6 month service maximum. 23 hours per episode No annual limit. Provider required to contact STR at time of admit. prior approval will be required. Cannot be provided within 6 months of most recent assessment prior approval will be required. 4 through 5 All All 3 II.1 5 through 6 III.1 Facility Based Crisis s S9484 Initial authorization 7 days 112 units Reauthorization every 4 days 64 units, no annual limit Prior approval will be required for first 7 days per episode 5 through 6 III.5 s must be in provider contract to be eligible for reimbursement

3 Alliance Behavioral Healthcare IPRS Adult Mental Health and Substance Abuse s Benefit Plan Group Living Moderate - Perinatal and maternal programs Group Living Moderate -Transitional Living Halfway House-SA Hospital Discharge Transition Inpatient Hospitalization Medication s Mobile Crisis Management YP770 YP770 H H2011 Authorization 365 days. III.1 30 day initial authorization. 45 day maximum length of stay per episode. Durham only III.1 Initial authorization 90 days, 180 day annual maximum Durham Only III.1 Up to128 units for 30 days Wake Only All Initial authorization for up to 3 days. Continuing stay requests authorized for up to 7 days 6 III.7 1 new patient visit and 8 established patient visits annually Established patients are not eligible for a New Patient Evaluation. 52 event limit for Billing limits: 32 units per day, 64 units per week, 320 per month, 640 per year Prior approval will be required. Cannot be provided within 6 months of most recent assessment. October 1, 2012 No prior approval required All I 3 through 6 s must be in provider contract to be eligible for reimbursement

4 Alliance Behavioral Healthcare IPRS Adult Mental Health and Substance Abuse s Benefit Plan Non-Hospital Medical Detoxification Opioid Treatment Outpatient s - Group H0010 H0020 H0004HQ H YP832 YP835 Authorization Request From Authorization 4 days, no annual maximum only, provider maintains copy of service plan 156 units for 180 days Reauthorization every 180 days Billing Limits: MH: 52 sessions annual limit, 2 sessions per week 9 per month when provided using a promising practice or evidenced based approach. SA: 180 sessions annual limit, 3 per week 15 per month. General group therapy 16 sessions. All H- s and YP-s, 6 units per session maximum Durham only Prior approval will be required. III.7- D I I s must be in provider contract to be eligible for reimbursement

5 Alliance Behavioral Healthcare IPRS Adult Mental Health and Substance Abuse s Benefit Plan Outpatient s- Individual Psychosocial Rehabilitation (PSR) Recovery Support SA Medically Monitored Community Residential Treatment (ADATC) SA Medically Managed Intensive Inpatient Detoxification (ADATC) H sessions annual H0004HR maximum. 2 sessions H0004HS per month billing limit. If consumer is receiving DBT, 26 individual session annual limit All H-s and YP- YP831 s 4 units per YP 833 session maximum. YP834 Authorization 180 days only, provider maintains copy up to 120 units per week. H2017 of service plan, if in other (3120 units per 180 enhanced service, PCP is days) (Initial + Rerequired. Authorization) Billing Limits: 8 units per YA325 only, provider to have plan in day, 16 per week, 40 per month, 240 unit annually. H0013 Authorization Request From Regional Referral Form Authorization Request From Regional Referral Form Initial authorization 14 days; Concurrent 7 days up to 28 days total Initial authorization 14 days; Concurrent 7 days up to 28 days total DBT requires diagnosis of BPD and 3. October 1, 2012 no prior approval for 2 individual sessions prior authorization required. Durham SA Providers Only I October 1, I III.7 IV-D s must be in provider contract to be eligible for reimbursement

6 Alliance Behavioral Healthcare IPRS Adult Mental Health and Substance Abuse s Benefit Plan SAIOP H months - 36 PCP/PCP update units/events. Minimum. 3 hrs per day 3 day per week Can request additional 2 weeks if clinically needed Supervised Living Moderate Supported Employment Group Supported Employment Individual YP720 YP640 YP630, PCP/PCP update only, provider to have plan in only, provider to have plan in Initial authorization 90 days. 180 day annual limit Up to 28 units/month per 180 day authorization period. 168 unit annual Max. TEP enrolled: Up to 40 units/week for 6 months. Non-TEP: Up to 40 units/month per for 6 months. Annual max 1040 Wake Only Wake Only Durham Only Durham Only II.1 3 through 5 through 2 through 2 s must be in provider contract to be eligible for reimbursement

7 Alliance Behavioral Healthcare IPRS Adult Mental Health and Substance Abuse s Benefit Plan Supported Employment Long Term follow-up Long-Term Vocational Support s (Extended) YM units for 6 months. only, provider to have plan in 208 Annual limit Durham Only through 2 Target Case Management H0032 Authorization Request From. PCP/PCP Updates Initial Authorization 90 days, 4 units for first 30 days and 4 units over 60 days. Concurrent Authorization 4 units for 60 days. All IPRS authorization will be end dated 12/31/2012. No new requests will be processed after 11/30/2012. Continuing 7/1/2012 no new consumers will be authorized in Durham. 2 through 5 II.1 s must be in provider contract to be eligible for reimbursement