PM Attachment 3.14.5
Prior Authorization Criteria
Behavioral Health Residential Facility (Child)
Require Prior Authorization and Re-Authorization of Residential Services for all members, regardless of eligibility status:
Routine admissions to a behavioral health residential facility are not emergent or urgent and always require prior authorization. A decision to prior
authorize admission into behavioral health residential facility will be made within seven (7) business days.
Urgent or emergent admissions to a behavioral health residential facility when used for hospital diversion, detention diversion for youth exhibiting
behavioral health symptoms/behaviors or crisis stabilization do not require prior authorization, but do require continued stay authorization on or before
the 6th calendar day after admission, including holidays and weekends.
Individuals referred for primary substance abuse treatment are exempt from Prior Authorization Criteria listed below.
Prior Authorization Required
Re-Authorization Required
Diagnostic Criteria
Behavior & Functioning
• Significant Risk of Harm
• Serious functional impairment that
is not developmentally appropriate
for self-care or self-regulation
*
Yes – Initial admission is valid for 60 days
Yes – Continued stay is valid for 60 days
Within 290-316.99 range as per DSM IV-TR
As a result of a DSM IV-TR diagnosis, the member has a significant risk of harm to
self or others or disturbance of mood, thought or behavior which renders the
child/adolescent incapable of developmentally appropriate self-care or selfregulation which is evidenced by recent or frequently recurring manifestations of the
following:
• At least one criterion in section 1; and
• The criteria in section 2; and
• Does not meet any of the exclusionary criterion in section 3
1. Significant recent or frequently recurring risk of harm as evidenced by:
a. Suicidal/homicidal ideation considered likely to lead to suicidal/homicidal
behaviors, and the inability of the individual and support system to carry out a
safety plan; or
b. Significant impulsivity with poor judgment/insight and a clear and persistent
inability of environmental supports to safely maintain the individual despite
intensive community based/in-home teams * ; or
c. Significant physical or sexual aggression with poor judgment and insight that
is the direct result of a behavioral health disorder that meets current DSM IVTR criteria, with the exception of conduct disorder; or
d. Risk of physiologic jeopardy which threatens health and functioning, for
example significant weight changes, water intoxication.
Community based/in-home teams – defined from Prioritized Covered Services
3.14.5 – Page 1 of 3
Last Revised: 06/28/2010
Effective Date: 02/05/2014
PM Attachment 3.14.5
Prior Authorization Criteria
Behavioral Health Residential Facility (Child)
Intensity of Services
Expected Response
2. Serious functional impairment of self-care or self-regulation as evidenced by the
documentation of psychiatric symptoms that clearly impair functioning, persist in
the absence of stressors, and seriously impair recovery from the presenting
problem.
3. The Level II admission is not used primarily, and therefore clinically
inappropriately, as:
a. An alternative to preventative detention, or as a means to ensure community
safety in a individual exhibiting primarily conduct disordered behavior; or
b. The equivalent of safe housing, permanency placement, or an alternative to
parent/guardian, CPS/DDD, or an agency’s ability to provide placement,
shelter or supervision for the child/adolescent; or
c. A behavioral health intervention when other less restrictive alternatives are
available and meet the child’s/adolescent’s treatment needs; including
situations when the youth/parent/legal guardian/caretaker are unwilling to
participate in these less restrictive alternatives including intensive in
home/community based teams; or
d. An intervention for runaway behavior.
Behavioral health residential facilities are OBHL-licensed behavioral health agencies
that provide structured treatment services. These facilities provide 24-hour
supervision and counseling and other therapeutic activities under the supervision of
an on-site or on-call behavioral health professional to children/adolescents who do
not require on-site medical services. A behavioral health residential facility provides
continuous treatment to a child/adolescent who is experiencing a behavioral health
issue that limits his/her independence but who is able to participate in treatment.
To be considered for admission to a behavioral health residential facility, all of the
following criteria must be met:
1. Intensity of services in the service plan is designed to discharge the member to a
home-like environment at the earliest possible time; and
2. Treatment should be at the least restrictive level of care consistent with the
child’s/adolescent’s need and therefore should not be instituted unless there is
documentation of a failure to respond to or professional judgment of an inability
to be safely managed in a less restrictive level of care; and
3. The medically necessary behavioral health services can be provided within a
therapeutic
home
setting.
Active
treatmentgroup
with the
services
available at this level of care can reasonably be
expected to improve the child’s/adolescent’s psychiatric condition in order to achieve
3.14.5 – Page 2 of 3
Last Revised: 06/28/2010
Effective Date: 02/05/2014
PM Attachment 3.14.5
Prior Authorization Criteria
Behavioral Health Residential Facility (Child)
Continuation of Care Criteria
Discharge Plan/Criteria
Review of Services/Wraparound
Needs for Individuals Denied
Placement
discharge from this setting at the earliest possible time and to facilitate return to
outpatient care and community living.
There is documented evidence that each of the following criteria is met:
1. Active treatment, available at this level of care, is being provided by the facility
on a 24 hour basis with direct supervision/oversight by professional behavioral
health staff and is documented in the facility clinical record; and
2. The treatment is reducing the severity of the behavioral health issue that was
identified as the reason for admission; and
3. Child Family Team meetings are being conducted as frequently as clinically
indicated to review progress and revise the service plan to address any lack of
progress; and
4. There is an expectation that continued treatment will improve or stabilize the
individual’s condition so that this type of service will no longer be needed; and
5. There is no less restrictive type of service available to safely meet the person’s
behavioral health needs; or
6. Significant regression of the member’s condition is anticipated without continuity
at this level of care; or
7. The member’s improved behavior and functioning during treatment at this level
of care has been very recent, and discharge at this time would be premature and
likely to result in significant regression.
1. There is a written discharge plan with specific discharge criteria and specific
recommendations for continued treatment that address the behavioral health
needs of the member, are cost effective, and may be provided in the least
restrictive environment, and
2. The discharge criteria identify the specific behaviors and impairment in
functioning leading to admission have improved, as identified through
accomplishment of service plan goals; or
3. The individual is not making progress toward the treatment goals and there is no
reasonable expectation of progress at this level of care.
If denying this level of care, CPSA will coordinate with the Comprehensive Service
Provider (CSP) who will develop recommendations for other interventions to
address the identified issues and needs. The CFT may use these recommendations
in re-formulating the child’s/adolescent’s service plan. This information will be
contained in the Notice of Action sent to the parent/legal guardian.
3.14.5 – Page 3 of 3
Last Revised: 06/28/2010
Effective Date: 02/05/2014