Members must be determined eligible for admission and
continued stay. Providers must maintain a member record for each member
documenting the medical necessity for psychiatric unit services. Documentation
must be available to the Department and its Authorized Agent. There must be
daily documentation that the admission criteria continues to be met for the
member to remain eligible for services.
45.09-1
Psychiatric Criteria
Members must meet all four (4) of the following criteria
to be eligible for psychiatric unit services, and must continue to meet all
four (4) of the following criteria in order to continue to be eligible for
psychiatric services:
1. The member
has a substantiated diagnosis found in the most current version of the American
Psychiatric Association's Diagnostic and Statistical Manual
(DSM).
2. Treatment is medically
necessary. Medical necessity must include one (1) or more of the following:
a. The member exhibits an immediate or direct
threat of serious harm to self or there is a clear and reasonable inference of
serious harm to self, where suicidal precautions or observations on a
24-hour/day basis are required. This behavior must require intensive
psychiatric, medical and nursing treatment interventions on a 24-hour day
basis.
b. The member is exhibiting
an immediate or direct threat of serious harm to others or there is evidence
for clear and reasonable inference of serious harm to others. This behavior
must require intensive psychiatric, medical and nursing treatment interventions
on a 24-hour/day basis.
c. The
member is exhibiting an extreme disabling condition such that one cannot take
care of self in a developmentally appropriate level or requires assistance
beyond the home or residential setting. The member's symptoms must be of such
severity that they require 24-hour/day intensive medical, psychiatric, and
nursing services. Outpatient treatment would be clearly unsafe or is
unavailable. A lower level of care is not available or would not be adequate to
successfully treat those symptoms.
3.
Age specific criteria
a. For members under the age of twenty-one
(21) or adults with a legal guardian:
i. The
member's family / guardian(s), where applicable and clinically indicated, are
willing to actively participate throughout the duration of treatment.
ii. The services can reasonably be expected
to improve the member's condition or prevent further regression so that
inpatient services will no longer be needed.
b. For members age sixty-five (65) or older,
services are the only alternative available to maintain or restore the member
to the greatest possible degree of health and independent
functioning.
4. A clear
indication that the inpatient psychiatric services offered provide the member
with active treatment.
45.09-2
Detoxification Criteria
Members must meet the following criteria to be eligible
for detoxification services.
The member's symptoms must meet American Society of
Addiction Medicine (ASAM) Level 4 criteria as defined in the most recent
edition of The ASAM Criteria: Treatment Criteria for Addictive,
Substance-related, and Co-Occurring Conditions:
a. Member must have Substance - Use or
Substance-Induced Disorder based upon DSM-5; and
b. Member must meet ASAM Level 4 Dimensions
1, 2, or 3.
