Current through Vol. 42, No. 1, September 16, 2024
(a)
Definition. Partial
hospitalization is an intermediary, stabilizing step for children and
adolescents who have had inpatient psychiatric hospitalization prior to
returning to school and community supports or as a less restrictive alternative
when inpatient treatment may not be indicated. PHP services are:
(1) Reasonable and necessary for the
diagnosis or active treatment of the member's condition; and
(2) Reasonably expected to improve the
member's condition and functional level and to prevent relapse or
hospitalization.
(b)
Eligibility criteria. This service must be prior authorized by
OHCA or its designated agent, and individuals must meet ongoing medical
necessity criteria. Treatment is time limited, and length of participation is
based on the individual's needs.
(c)
Eligible providers. Provider
agencies for PHP must be accredited to provide partial hospitalization services
by The Joint Commission (TJC), the Commission on Accreditation of
Rehabilitation Facilities (CARF), the Accreditation Commission for Health Care
(ACHC) or The Council on Accreditation (COA) for partial hospitalization and
enrolled in SoonerCare. Staff providing these services are employees or
contractors of the enrolled agency. The agency is responsible for ensuring that
all services are provided by properly credentialed clinicians.
(d)
Qualified practitioners.
Program services are overseen by a psychiatrist. The number of professionals
and paraprofessionals required on the clinical team is dependent on the size of
the program. The clinical team includes the following required professionals:
(1) A licensed physician, physician's
assistant, or advanced practice registered nurse [any of whom meet the
requirements of an LBHP as described at OAC
317:30-5-240.3(a)]
;
(2) Registered nurse;
and
(3) One (1) or more LBHPs or
licensure candidates listed in OAC
317:30-5-240.3(a) and
(b).
(4) The clinical team may also include a
certified behavioral health case manager.
(e)
Service components. PHP
includes the following services:
(1)
Assessment, diagnostic and service plan services for mental illness and/or
substance use disorders provided by LBHPs or licensure candidates;
(2) Individual/group/family (primary purpose
is treatment of the member's condition) psychotherapies provided by LBHPs or
licensure candidates;
(3) Substance
use disorder specific services are provided by LBHPs or licensure candidates
qualified to provide these services;
(4) Drugs and biologicals furnished for
therapeutic purposes;
(5) Family
counseling, the primary purpose of which is treatment of the member's
condition;
(6) Behavioral health
rehabilitation services to the extent the activities are closely and clearly
related to the member's care and treatment, provided by a certified behavioral
health case manager II, certified alcohol and drug counselor (CADC), LBHP, or
licensure candidate who meets the professional requirements listed in OAC
317:30-5-240.3;
and
(7) Care coordination of
behavioral health services provided by certified behavioral health case
managers.
(f)
Limitations. Services are subject to the following:
(1) Children under age six (6) are not
eligible for behavioral health rehabilitation services unless a prior
authorization for children ages four (4) and five (5) has been granted by OHCA
or its designated agent based on a finding of medical necessity.
(2) Services must be offered at a minimum of
three (3) hours per day, five (5) days per week.
(3) Therapeutic services are limited to four
(4) billable hours per day.
(4)
Group size is limited to a maximum of eight (8) individuals as clinically
appropriate given diagnostic and developmental functioning.
(5) Occupational, physical and speech therapy
will be provided by the Independent School District (ISD). Academic
instruction, meals, and transportation are not covered.
(6) PHP services cannot be billed in
conjunction with the following:
(A) Children's
psychosocial rehabilitation services;
(B) Residential services [psychiatric
residential treatment facility (PRTF) or residential behavior management
services (RBMS)];
(C) Targeted case
management (TCM);
(D) Individual,
family, or group therapy;
(E)
Mobile crisis intervention within the PHP setting;
(F) Peer-to-peer services;
(G) Certified Community Behavioral Health
(CCBH) services;
(H) Day
treatment;
(I) Multi-systemic
therapy (MST);
(J) Program of
Assertive Community Treatment (PACT) [Applicable for individuals eighteen (18)
to twenty-one (21) years of age].
(g)
Service requirements. This
service includes:
(1) Therapeutic services
that include the following:
(A)
Psychiatrist/physician face-to-face visit two (2) times per month;
and
(B) Crisis management services
available twenty-four (24) hours a day, seven (7) days a week.
(2) Psychotherapies that are
provided at a minimum of four (4) hours per week and include the following:
(A) Individual therapy - a minimum of one (1)
session per week;
(B) Family
therapy - a minimum of one (1) session per week; and
(C) Group therapy - a minimum of two (2)
sessions per week.
(3)
Interchangeable services that include the following:
(A) Behavioral health case management
(face-to-face);
(B) Behavioral
health rehabilitation services/alcohol and other drug abuse education, except
for children under age six (6), unless a prior authorization has been granted
for children ages four (4) and five (5);
(C) Medication training and support;
and
(D) Expressive
therapy.
(h)
Documentation requirements. Documentation needs to specify active
involvement of the member's family, caretakers, or significant others involved
in the individual's treatment. A nursing health assessment must be completed
within twenty-four (24) hours of admission. A physical examination and medical
history must be coordinated with the primary care physician. Service plan
updates are required every three (3) months or more frequently based on
clinical need. Records must be documented according to OAC
317:30-5-248.
(i)
Staffing requirements.
Staffing must consist of the following:
(1) A
registered nurse (RN) trained and competent in the delivery of behavioral
health services as evidenced by education and/or experience that is available
on-site during program hours to provide necessary nursing care and/or
psychiatric nursing care [one (1) RN at a minimum can be backed up by a
licensed practical nurse (LPN) but an RN must always be on site]. Nursing staff
administers medications, follows up with families on medication compliance, and
completes restraint assessments;
(2) Medical director must be a licensed
psychiatrist;
(3) A
psychiatrist/physician must be available twenty-four (24) hours a day, seven
(7) days a week.
(4) One (1) or
more LBHPs or licensure candidates listed in OAC
317:30-5-240.3(a) and
(b).
(j)
Reimbursement. PHP services
are reimbursed pursuant to the methodology described in the Oklahoma Medicaid
State Plan. PHP reimbursement is all-inclusive of the service components,
except for the following:
(A) Physician
services;
(B)
Medications;
(C) Psychological
testing by a licensed psychologist.
