Current through 2024-38, September 18, 2024
Members must be determined eligible for admission and
continued stay. Providers must maintain a member record for each member
documenting the medical necessity for these services. Documentation must be
available to the Department and its Authorized Agent. There must be daily
documentation that the admission criteria continue to be met for the member to
remain eligible for services unless otherwise noted.
46.09-1
Psychiatric Criteria
Members must meet all of the following four (4) criteria
in order 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.
46.09-2
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's (ASAM) Level IV criteria as defined in the most recent
edition of the ASAM Patient Placement Criteria (ASAM PPC-2R):
a. Member must have Substance -Use or
Substance-Induced Disorder based upon DSM-IV TR; and
b. Member must meet ASAM Level IV Dimensions
1, 2 or 3.
46.09-3
Developmental Disorders Unit Criteria
Members under age 21 must meet the following four (4)
criteria to qualify for Developmental Disorders Unit services:
1. A diagnosis of Mental Retardation or a
Pervasive Developmental Disorder Axis I or II from the most current version of
the Diagnostic and Statistical Manual of Mental Disorders; and
2. A Global Assessment Functioning score of
35 or lower (this admission criteria does not need to be met as part of the
continuing stay criteria); and
3.
Member's symptoms must be of such severity that they require intensive medical,
psychiatric and nursing services; and one or both of the following:
a. High frequency, intensity and duration of
intervention is required to address repeated aggression or self-injury severe
enough to have caused serious injury, or there is significant potential of
serious injury to self or others; or
b. Symptoms of Mental Retardation or
Pervasive Developmental Disorder are of such severity that one is unable to
care for oneself at a developmentally appropriate level, and treatment at a
less restrictive level of care would be unsafe or is unavailable; and
4. Member has not previously
responded to a less restrictive level of care; or would have a significant risk
of harm to self or others, or serious functional deterioration would occur, if
a less restrictive setting was used.
