PMA 10.1.2
CONTINUED PSYCHIATRIC ACUTE OR SUB-ACUTE
FACILITIES AUTHORIZATION CRITERIA
Cenpatico Integrated Care (C-IC) uses medical necessity criteria from the American Society of Addiction
Medicine (ASAM) for authorization of substance-related treatment. C-IC uses McKesson’s InterQual medical
necessity criteria for residential behavioral health inpatient facility authorizations. The InterQual criteria are
summarized below.
FOR PRIOR AUTHORIZATION
For admission to this level of care, a person under the age of eighteen years must meet both Clinical Indication
criteria 1 and 2 in section A, both Social Risk criteria 1 and 2 in section B and one Level of Care criterion in
section C.
A. CLINICAL INDICATION: Both criterion 1 and 2 must be present within the last week
1. Current psychiatric diagnosis cannot be managed safely at a less intensive level of care
2. Symptoms or behavior: all three criteria must be met:
a. Chronic or persistent danger to self or others as evidenced by one of the following:
i. Fire setting
ii. Non-suicidal self-injury
iii. Runaway for more than 24 hours and places self in dangerous situations
iv. Daredevil or impulsive behavior
v. Perpetrator of sexually inappropriate, aggressive or abusive behavior
vi. Unmanageable behaviors: one of the following:
 Angry outbursts or aggression
 Delusions, hallucinations, disorganized thoughts, speech or behavior
 Increased hypomanic symptoms in adolescents
 Encopresis with feces smearing in persons under thirteen years of age
 Engaging in delinquent acts in persons under thirteen years of age
 Persistent violation of court orders in persons under thirteen years of age
vii. Confirmed illegal activity or arrest in adolescents
viii. Persistent violation of court orders in adolescents
b. Danger to self or others present for at least six months
c. Behaviors are expected to persist longer than a year without treatment
B. SOCIAL RISKS: Both criterion 1 and 2 must be met
1. Unsuccessful treatment within the last year as evidenced by one of the following:
a. Intensive community-based treatment
b. HCTC services
c. Behavioral Health Residential Facility
d. At least three psychiatric inpatient admissions
e. At least four psychiatric admissions to any combination of inpatient and intensive outpatient services
2. Support system: one of the following is present within the last month:
a. Unavailable
b. Unable to ensure safety
c. High-risk environment
d. Abusive
e. Intentional sabotage of treatment
f. Unable to manage intensity of person’s symptoms
C. LEVEL OF CARE: One of the following criterion must be met
1. Discharge or transfer from a psychiatric hospital within the last 24 hours AND one of the following:
a. Persistent, severe, medication-refractory/resistant psychiatric symptoms
b. Hostile or intimidating interactions
2. Unable or unwilling to follow instructions or negotiate needs
3. Unable to maintain behavioral control for more than 48 hours AND improvement is expected within the
next two weeks
FOR CONTINUED STAY AUTHORIZATION
For authorization of continued service at this level of care, a person must meet at least one Current Symptom
PMA 10.1.2
Effective 10/1/2015
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Revised 12/11/2015
criterion in section A, one Functioning criterion in section B and all six Service criteria in section C.
A. CURRENT SYMPTOMS OR BEHAVIOR: One of the following criteria within the last week
1. Disruptive behavior, one of the following within the last week:
i. Physical altercation or angry outbursts
ii. Destruction of property
iii. Easily frustrated and impulsive
iv. Perpetrator of sexually inappropriate, aggressive or abusive behavior
v. Runaway from facility or while on home pass
vi. Persistent rule violations
2. Psychomotor agitation or retardation
3. Depersonalization or derealization
4. Hypervigilance or paranoia
5. Non-suicidal self-injury
6. Suicidal or homicidal ideation without intent
7. One of the following psychiatric medication refractory/resistant symptoms persists or is increasing
i. Anxiety and associated symptoms
ii. Depressed or irritable mood and associated symptoms
iii. Hypomanic symptoms
iv. Obsessions or compulsions
v. Psychosis and associated symptoms
8. Symptoms or behavior are improved and discharge is planned within the next week AND one of the
following:
i. Treatment goals are not met
ii. Family or guardian requires further intervention AND return to family is planned
B. FUNCTIONING: One of the following within the last week:
1. Unable or unwilling to follow instructions or negotiate needs
2. Interpersonal conflict as evidenced by one of the following:
i. Accusatory, threatening or manipulative behavior
ii. Hostile or intimidating behavior
iii. Poor or intrusive boundaries
iv. Unable to establish positive peer or adult relationships
3. Repeated privilege restriction or loss of privileges
4. Improved independent functioning with discharge planned within the next week AND therapeutic passes
are planned to transition to an alternate level of care
C. SERVICES: All of the following services within the last week
1. Psychiatric evaluation at least twice a week
2. Clinical assessment at least daily
3. Individual or family psycho-education for adolescents; family psycho-education for children
4. For adolescents: individual, group or family therapy at least five times per week; For children: individual or
group therapy at least four times per week and family therapy at least once a week
5. Behavioral contract or symptom management plan
6. School or vocational program
PMA 10.1.2
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